Urethral Stricture Disease Unabridged FINAL 060923

Any person or company accessing this guideline with the intent of using the guideline for promotional purposes
must obtain a licensable copy.
American Urological Association (AUA)
A PPROVED BY THE AUA URETHRAL STRICTURE DISEASE: AUA GUIDELINE

B OARD OF D IRECTORS APRIL
2023
Authors’ disclosure of potential

(Published 2016; Amended 2023)
conflicts of interest and
author/staff contributions appear Hunter Wessells, MD; Kenneth W. Angermeier, MD; Sean P. Elliott, MD; Christopher
at the end of the article.
M. Gonzalez, MD; Ron T. Kodama, MD; Andrew C. Peterson, MD; James Reston, PhD;
© 2023 by the American Keith Rourke, MD; John T. Stoffel, MD; Alex Vanni, MD; Bryan Voelzke, MD; Lee Zhao,
Urological Association
MD; Richard A. Santucci, MD
Amendment: Hunter Wessells, MD; Allen Morey, MD; Lesley Souter, PhD; Alex Vanni,
MD
SUMMARY
Purpose
The clinical guideline on urethral stricture provides a clinical framework for the diagnosis of urethral stricture and includes
discussion of initial management, urethroplasty, reconstruction, contracture, stenosis, special circumstances, and post-
operative follow-up care.
Methodology
A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1990 to
12/1/2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture
in men. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. The search for
the 2023 Amendment used the Ovid, MEDLINE, Embase, and ClinicalTrials.gov databases and was modified to included
females and males (search dates 12/2015 – 10/2022 for males; 01/1990 – 10/2022 for females) and one new Key Question
on sexual dysfunction outcomes in men with bulbar urethral strictures was added (search dates: 01/1990 – 10/2022). All
searches yielded 11,752 citations; after inclusion and exclusion criteria were applied, 81 studies were added to the existing
evidence base. These publications were used to create the guideline statements. If sufficient evidence existed, then the
body of evidence for a particular treatment was assigned a rating of A (high quality evidence; high certainty), B (moderate
quality evidence; moderate certainty), or C (low quality evidence; low certainty) and evidence-based statements of Strong,
Moderate, or Conditional Recommendation based on risks and benefits were developed. Additional information is provided
as Clinical Principles and Expert Opinions when insufficient evidence existed.
GUIDELINE STATEMENTS
DIAGNOSIS/INITIAL MANAGEMENT
1. Clinicians should include urethral stricture in the differential diagnosis of patients who present with decreased
urinary stream, incomplete emptying, dysuria, urinary tract infection, and after rising post-void residual. (Moderate
Recommendation; Evidence Level: Grade C)
Copyright © 2023 American Urological Association Education and Research, Inc. ®

Any person or company accessing this guideline with the intent of using the guideline for promotional purposes must obtain a licensable copy.
Urethral Stricture Disease
2. After performing a history, physical examination, and urinalysis, clinicians may use a combination of patient reported
measures, uroflowmetry, and ultrasound post-void residual assessment in the initial evaluation of suspected
urethral stricture. (Clinical Principle)
3. Clinicians should use urethro-cystoscopy, retrograde urethrography, voiding cystourethrography, or ultrasound
urethrography to make a diagnosis of urethral stricture. (Moderate Recommendation; Evidence Level: Grade C)
4. Clinicians planning non-urgent intervention for a known stricture should determine the length and location of the
urethral stricture. (Expert Opinion)
5. Surgeons may utilize urethral endoscopic management (e.g., urethral dilation, direct visual internal urethrotomy) or
immediate suprapubic cystostomy for urgent management of urethral stricture, such as discovery of symptomatic
urinary retention or need for catheterization prior to another surgical procedure. (Expert Opinion)
6. Surgeons may place a suprapubic cystostomy to promote “urethral rest” prior to definitive urethroplasty in patients
dependent on an indwelling urethral catheter or intermittent self-dilation. (Conditional Recommendation; Evidence
Level: Grade C)
DILATION/INTERNAL URETHROTOMY/URETHROPLASTY
7. Surgeons may offer urethral dilation, direct visual internal urethrotomy, or urethroplasty for the initial treatment of a
short (<2cm) bulbar urethral stricture. (Conditional Recommendation; Evidence Level: Grade C)
8. Surgeons may perform either dilation or direct visual internal urethrotomy when performing endoscopic treatment
of a urethral stricture. (Conditional Recommendation; Evidence Level: Grade C)
9. Surgeons may safely remove the urethral catheter within 72 hours following uncomplicated dilation or direct visual
internal urethrotomy. (Conditional Recommendation; Evidence Level: Grade C)
10. In patients who are not candidates for urethroplasty, clinicians may recommend self-catheterization after direct
visual internal urethrotomy to maintain urethral patency. (Conditional Recommendation; Evidence Level: Grade C)
11 a. Surgeons should offer urethroplasty, instead of repeated endoscopic management for recurrent anterior urethral
strictures following failed dilation or direct visual internal urethrotomy. (Moderate Recommendation; Evidence Level:
Grade C)
11 b. Surgeons may offer urethral dilation or direct visual internal urethrotomy, combined with drug-coated balloons,
for recurrent bulbar urethral strictures <3cm in length. (Conditional Recommendation; Evidence Level: Grade B)
12. Surgeons who do not perform urethroplasty should refer patients to surgeons with expertise. (Expert Opinion)
ANTERIOR URETHRAL RECONSTRUCTION

13. Surgeons may initially treat meatal or fossa navicularis strictures with either dilation or meatotomy. (Clinical
Principle)
14. Surgeons should offer urethroplasty to patients with recurrent meatal or fossa navicularis strictures. (Moderate
15. Surgeons should offer urethroplasty to patients with penile urethral strictures given the expected high recurrence
rates with endoscopic treatments. (Moderate Recommendation; Evidence Level: Grade C)
16. Surgeons should offer urethroplasty as the initial treatment for patients with long (≥2cm) bulbar urethral
stricturesgiven the low success rate of direct visual internal urethrotomy or dilation. (Moderate Recommendation;
Evidence Level: Grade C)

17. Surgeons may reconstruct long multi-segment strictures with one-stage or multi-stage techniques using oral
mucosal grafts, penile fasciocutaneous flaps, or a combination of these techniques. (Moderate Recommendation;
18 a. Surgeons may offer perineal urethrostomy as a long-term treatment option to patients as an alternative to
urethroplasty. (Conditional Recommendation; Evidence Level: Grade C)
18 b. Surgeons should offer perineal urethrostomy as a long-term treatment option to patients as an alternative to
urethroplasty in patient populations at high risk for failure of urethral reconstruction. (Expert Opinion)
19 a. Surgeons should use oral mucosa as the first choice when using grafts for urethroplasty. (Expert Opinion)
19 b. Surgeons may use either buccal or lingual mucosal grafts as equivalent alternatives. (Strong Recommendation;
Evidence Level: Grade A)
20. Surgeons should not perform substitution urethroplasty with allograft, xenograft, or synthetic materials except under
experimental protocols. (Expert Opinion)
21. Surgeons should not perform a single stage tubularized graft urethroplasty. (Expert Opinion)
22. Surgeons should not use hair-bearing skin for substitution urethroplasty. (Clinical Principle)
PELVIC FRACTURE URETHRAL INJURY

23. Clinicians should use retrograde urethrography with voiding cystourethrogram and/or retrograde + antegrade
cystoscopy for preoperative planning of delayed urethroplasty after pelvic fracture urethral injury. (Moderate
24. Surgeons should perform delayed urethroplasty instead of delayed endoscopic procedures after urethral
obstruction/obliteration due to pelvic fracture urethral injury. (Expert Opinion)
25. Definitive urethral reconstruction for pelvic fracture urethral injury should be planned only after major injuries
stabilize and patients can be safely positioned for urethroplasty. (Expert Opinion)
FEMALE URETHRAL RECONSTRUCTION

26. Surgeons may reconstruct female urethral strictures using oral mucosal grafts, vaginal flaps, or a combination of
these techniques. (Moderate Recommendation; Evidence Level: Grade C)
BLADDER NECK CONTRACTURE/VESICOURETHRAL STENOSIS

27. Surgeons may perform a dilation, bladder neck incision, or transurethral resection for bladder neck contracture after
endoscopic prostate procedure. (Expert Opinion)
28. Surgeons may perform a dilation, vesicourethral incision, or transurethral resection for post-prostatectomy
vesicourethral anastomotic stenosis. (Conditional Recommendation; Evidence Level: Grade C)
29. Surgeons may perform robotic or open reconstruction for recalcitrant stenosis of the bladder neck or post-
prostatectomy vesicourethral anastomotic stenosis. (Conditional Recommendation; Evidence Level: Grade C)
SPECIAL CIRCUMSTANCES
30. In men who require chronic self-catheterization (e.g., neurogenic bladder), surgeons may offer urethroplasty as a
treatment option for urethral stricture causing difficulty with intermittent self-catheterization. (Expert Opinion)

LICHEN SCLEROSUS
31. Clinicians may perform biopsy for suspected lichen sclerosus and must perform biopsy if urethral cancer is
suspected. (Clinical Principle)
32. In lichen sclerosus-proven urethral stricture, surgeons should not use genital skin for reconstruction. (Strong
Recommendation; Evidence Level: Grade B)
POST-OPERATIVE FOLLOW-UP
33. Clinicians should monitor urethral stricture patients to identify symptomatic recurrence following dilation, direct
visual internal urethrotomy, or urethroplasty. (Expert Opinion)

management of acute pelvic fracture urethral injury

INTRODUCTION (PFUI) or pelvic fracture urethral disruption; urethral
cancer not related to stricture; or voiding symptoms not
PURPOSE related to stricture. Studies with less than 10 patients
were generally excluded from further evaluation and thus
Urethral stricture is chronic fibrosis and narrowing of the data extraction given the unreliability of the statistical
urethral lumen caused by acute injury, inflammatory estimates and conclusions that could be derived from
conditions, and iatrogenic interventions including urethral them. In rare instances, we have included studies with
instrumentation, surgery, and prostate cancer treatment. less than 10 patients or studies preceding the literature
The symptoms of urethral stricture are non-specific and search date if no other evidence was identified. For
may overlap with other common conditions that confound certain key questions that had little or no evidence from
timely diagnosis, including lower urinary tract symptoms comparative studies, we included case series with 50 or
(LUTS) and urinary tract infections (UTI). Urologists play more patients. Review article references were checked to
a key role in the initial evaluation of urethral stricture and ensure inclusion of all possible relevant studies. Multiple
currently provide all accepted treatments. Thus, reports on the same patient group were carefully
urologists must be familiar with the evaluation and examined to ensure inclusion of only non-redundant
diagnostic tests for urethral stricture as well as information. The systematic review yielded a total of 250
endoscopic and open surgical treatments. This guideline publications relevant to preparation of the guideline.
provides evidence-based guidance to clinicians and
patients regarding how to recognize symptoms and signs QUALITY OF INDIVIDUAL STUDIES AND
of a urethral stricture/stenosis, carry out appropriate DETERMINATION OF EVIDENCE STRENGTH
testing to determine the location and severity of the The quality of individual studies that were either
stricture, and recommend the best options for treatment. randomized controlled trials (RCTs) or clinical controlled
The most effective approach for a particular patient is best trials was assessed using the Cochrane Risk of Bias
determined by the individual clinician and patient in the tool.1 Observational cohort studies with a comparison of
context of that patient's history, values, and goals for interest were evaluated with the Drug Effectiveness
treatment. As the science relevant to urethral stricture Review Project instrument.2 Conventional diagnostic
evolves and improves, the strategies presented here will cohort studies, diagnostic case-control studies, or
be amended to remain consistent with the highest diagnostic case series that presented data on diagnostic
standards of clinical care. test characteristics were evaluated using the QUADAS 2
tool, which evaluates the quality of diagnostic accuracy
METHODOLOGY studies.3
2016 Guideline The categorization of evidence strength is conceptually

distinct from the quality of individual studies. Evidence
A systematic review for the 2016 guideline was conducted strength refers to the body of evidence available for a
to identify published articles relevant to the diagnosis and particular question and includes not only individual study
treatment of urethral stricture in men. Literature searches quality but also consideration of study design, consistency
were performed on English-language publications using of findings across studies, adequacy of sample sizes, and
the Pubmed, Embase, and Cochrane databases from generalizability of samples, settings, and treatments for
1/1/1990 to 12/1/2015 by the ECRI Institute and were the purposes of the guideline. The American Urological
included in a systematic review evidence report. Association (AUA) categorizes the level of a body of
Preclinical studies (e.g., animal models), commentary, evidence as Grade A (well-conducted and highly-
editorials, non-English language publications, and generalizable RCTs or exceptionally strong observational
meeting abstracts were excluded. Additional exclusion studies with consistent findings); Grade B (RCTs with
criteria were as follows: studies of females; studies of some weaknesses of procedure or generalizability or
stricture prevention; patients with epispadias, congenital moderately strong observational studies with consistent
strictures, and duplicated urethra; trauma already findings); or Grade C (RCTs with serious deficiencies of
covered under trauma guidelines including diagnosis and procedure, generalizability, or extremely small sample

sizes or observational studies that are inconsistent, have bulbar urethral strictures were excluded, and the evidence
small sample sizes, or have other problems that base was comprised of RCTs and comparative cohort
potentially confound interpretation of data). By definition, studies. This exclusion criterion was retained in the
Grade A evidence is evidence about which the Panel has amendment when evaluating studies that enrolled male or
a high level of certainty, Grade B evidence is evidence both male and female populations. However, based on a
about which the Panel has a moderate level of certainty, paucity of data, single-arm studies that enrolled a solely
and Grade C evidence is evidence about which the Panel female population were retained. Following study
has a low level of certainty. 4 selection, 81 studies were included in the amendment
evidence base.
2023 Amendment
INDIVIDUAL STUDY QUALITY AND
The 2016 guideline search strategy was modified to POTENTIAL FOR BIAS
include females in addition to males and was used to
Quality assessment for all retained studies was
systematically search Ovid, MEDLINE, Embase, and
conducted. Using this method, studies deemed to be of
ClinicalTrials.gov databases for new evidence published
low quality would not be excluded from the systematic
between December 2015 and October 2022. A second
review, but would be retained, and their methodological
search was designed to only identify female urethral
strengths and weaknesses discussed where relevant. To
stricture studies published between January 1990 and
define an overall study quality rating for each included
December 2015, the timeframe covered in the original
study, risk of bias as determined by validated study-type
guideline for male patients. Finally, a third search
specific tools was paired with additional important quality
(January 1990 – October 2022) was developed to
features. AMSTAR-2 was used for assessment of
address a new Key Question comparing sexual
systematic review with and without meta-analyses.6 To
dysfunction outcomes in men with bulbar urethral
evaluate the risk of bias within the identified RCTs, the
strictures receiving either non-transecting anastomotic
Cochrane Risk of Bias Tool7 was employed, while for
urethroplasty procedures or transecting procedures.
observational studies, a Risk of Bias in Non-Randomized
Titles and abstracts of studies identified by all searches
Studies – of Intervention (ROBINS-I) tool8 was used.
were reviewed in a two-stage process. During the first
Additional important quality features, such as study
stage, studies were reviewed to determine if they
design, comparison type, power of statistical analysis,
assessed urethral stricture in males or females, and if
and sources of funding were extracted for each study.
they met the study selection criteria of prespecified study
type, minimum allowable sample size, and if published in CERTAINTY OF EVIDENCE BY GRADE
English. Allowable study types included systematic
The Grading of Recommendations, Assessment,
reviews, RCTs, diagnostic accuracy studies, cohort
Development, and Evaluation (GRADE) system was used
studies with and without comparison group, case-control
to determine the aggregate evidence quality for each
studies, and case series. All other study types were
recommendation statement.9 GRADE defines a body of
excluded. Only studies that enrolled at least 10 patients
evidence in relation to how confident guideline developers
were considered for inclusion in the evidence base.
can be that the estimate of effects as reported by that
During the second stage of title and abstract review,
body of evidence is correct. Evidence is categorized as
abstracts were compared to the PICO criteria.
high, moderate, low, and very low, and assessment is
Additionally, studies were assessed to determine if they
based on the aggregate risk of bias for the evidence base,
either directly informed the Key Questions or if they
plus limitations introduced as a consequence of
presented data that could reaffirm or refute the original
inconsistency, indirectness, imprecision and publication
guideline statements.
bias across the studies.10 Upgrading of evidence is
In the original ECRI evidence report that underpinned the possible if the body of evidence indicates a large effect or
male urethral stricture guideline,5 single-arm if confounding would suggest either spurious effects or
observational studies that evaluated urethroplasty or would reduce the demonstrated effect.

Table 1: Level of Evidence Definitions

AUA Level of GRADE Certainty Definition
Evidence Category Rating
A High  Very confident that the true effect lies close to that of the
estimate of the effect
B Moderate  Moderately confident in the effect estimate

 The true effect is likely to be close to the estimate of the effect,
but there is a possibility that it is substantially different
C Low  Confidence in the effect estimate is limited

 The true effect may be substantially different from the estimate
of the effect
Very Low  Very little confidence in the effect estimate

 The true effect is likely to be substantially different from the
estimate of effect
The AUA employs a 3-tiered strength of evidence system any body of evidence grade. Grade A evidence in support
to underpin evidence-based guideline statements. Table of a Strong or Moderate Recommendation indicates that
1 summarizes the GRADE categories, definitions, and the statement can be applied to most patients in most
how these categories translate to the AUA strength of circumstances and that future research is unlikely to
evidence categories. In short, high certainty by GRADE change confidence. Grade B evidence in support of a
translates to AUA A-category strength of evidence, Strong or Moderate Recommendation indicates that the
moderate to B, and both low and very low to C statement can be applied to most patients in most
circumstances, but that better evidence could change
AUA NOMENCLATURE: LINKING confidence. Grade C evidence in support of a Strong or
STATEMENT TYPE TO EVIDENCE LEVEL Moderate Recommendation indicates that the statement
The AUA nomenclature system explicitly links statement can be applied to most patients in most circumstances,
type to body of evidence level, degree of certainty, but that better evidence is likely to change confidence.
magnitude of benefit or risk/burdens, and the Panel's Grade C evidence is only rarely used in support of a
judgment regarding the balance between benefits and Strong Recommendation. Conditional Recommendations
risks/burdens (Table 2). Strong Recommendations are also can be supported by Grade A, B, or C evidence.
directive statements that an action should (benefits When Grade A is used, the statement indicates that
outweigh risks/burdens) or should not (risks/burdens benefits and risks/burdens appear balanced, the best
outweigh benefits) be undertaken because net benefit or action depends on patient circumstances, and future
net harm is substantial. Moderate Recommendations are research is unlikely to change confidence. When Grade B
directive statements that an action should (benefits evidence is used, benefits and risks/burdens appear
outweigh risks/burdens) or should not (risks/burdens balanced, the best action also depends on individual
outweigh benefits) be undertaken because net benefit or patient circumstances and better evidence could change
net harm is moderate. Conditional Recommendations are confidence. When Grade C evidence is used, there is
non-directive statements used when the evidence uncertainty regarding the balance between benefits and
indicates that there is no apparent net benefit or harm or risks/burdens, alternative strategies may be equally
when the balance between benefits and risks/burden is reasonable, and better evidence is likely to change
unclear. All three statement types may be supported by confidence.

Table 2: AUA Nomenclature Linking Statement Type to Degree of Certainty, Magnitude of Benefit or Risk/Burden,
and Body of Evidence Level
Evidence Grade Evidence Level: Grade A Evidence Level: Grade B Evidence Level: Grade C
(High Certainty) (Moderate Certainty) (Low Certainty)
Strong -Benefits > Risks/Burdens -Benefits > Risks/Burdens (or -Benefits > Risks/Burdens (or
Recommendation (or vice versa) vice versa) vice versa)
(Net benefit or -Net benefit (or net harm) is -Net benefit (or net harm) is -Net benefit (or net harm)
harm substantial) substantial substantial appears substantial
-Applies to most patients in -Applies to most patients in -Applies to most patients in
most circumstances and most circumstances but most circumstances but better
future research is unlikely to better evidence could change evidence is likely to change
change confidence confidence confidence (rarely used to
support a Strong
Recommendation)
Moderate -Benefits > Risks/Burdens -Benefits > Risks/Burdens (or -Benefits > Risks/Burdens (or
Recommendation (or vice versa) vice versa) vice versa)
(Net benefit or -Net benefit (or net harm) is -Net benefit (or net harm) is -Net benefit (or net harm)
harm moderate) moderate moderate appears moderate
-Applies to most patients in -Applies to most patients in -Applies to most patients in
most circumstances and most circumstances but most circumstances but better
future research is unlikely to better evidence could change evidence is likely to change
change confidence confidence confidence
Conditional -Benefits=Risks/Burdens -Benefits= Risks/Burdens -Balance between Benefits &

Recommendation -Best action depends on -Best action appears to Risks/Burdens unclear
(Net benefit or individual patient depend on individual patient -Net benefit (or net harm)
harm comparable circumstances circumstances comparable to other options
to other options) -Future Research is unlikely -Better evidence could -Alternative strategies may be
to change confidence change confidence equally reasonable
-Better evidence likely to change
confidence
Clinical Principle a statement about a component of clinical care that is widely agreed upon by urologists or other
clinicians for which there may or may not be evidence in the medical literature
Expert Opinion a statement, achieved by consensus of the Panel, that is based on members' clinical training,
experience, knowledge, and judgment for which there may or may not be evidence in the
medical literature

For some clinical issues, particularly diagnosis, there was BACKGROUND

little or no evidence from which to construct evidence-
based statements. Where gaps in the evidence existed, The urethra extends from the bladder neck, which is
the Panel provides guidance in the form of Clinical composed of smooth muscle circular fibers, to the
Principles or Expert Opinion with consensus achieved meatus, with varying histological features and stromal
using a modified Delphi technique if differences of opinion support based on anatomical location. The components
emerged.11 A Clinical Principle is a statement about a of the posterior urethra are lined with transitional
component of clinical care that is widely agreed upon by epithelium, whereas the male anterior urethra is lined with
urologists or other clinicians for which there may or may pseudostratified columnar epithelium that changes to
not be evidence in the medical literature. Expert Opinion stratified squamous epithelium in the fossa navicularis.
refers to a statement, achieved by consensus of the The posterior urethra includes both the prostatic and
Panel, that is based on members' clinical training, membranous urethra in men whereas in women it
experience, knowledge, and judgment for which there is consists solely of the membranous urethra. The prostatic
no evidence. urethra extends from the distal bladder neck to the distal
end of the veru montanum. The distal external sphincter
Panel Formation and Review mechanism surrounds the membranous urethra and is
comprised of both intrinsic smooth muscle and
The Urethral Stricture Panel was created in 2013 by the rhabdosphincter. The anterior urethra includes the bulbar
American Urological Association Education and urethra, penile urethra, and fossa navicularis. This portion
Research, Inc. The Practice Guidelines Committee (PGC) of the urethra is surrounded by the corpus spongiosum,
of the AUA selected the Panel Co-Chairs who in turn which in the bulbar urethra is surrounded by the
appointed the additional panel members with specific bulbocavernosus muscle. The fossa navicularis is located
expertise in this area. The AUA conducted a thorough entirely within the glans penis.
peer review process. The draft guidelines document was
Urethral stricture is the preferred term for any abnormal
distributed to 90 peer reviewers. The panel reviewed and
narrowing of the anterior urethra, which runs from the
discussed all submitted comments and revised the draft
bulbar urethra to the meatus and is surrounded by the
as needed. Once finalized, the guideline was submitted
corpus spongiosum. Urethral strictures are associated
for approval to the PGC and the AUA Science and Quality
with varying degrees of spongiofibrosis. Narrowing of the
Council. Then it was submitted to the AUA Board of
posterior urethra, which lacks surrounding spongiosum, is
Directors for final approval. Funding of the panel was
thus referred to as a "stenosis." PFUI typically creates a
provided by the AUA; panel members received no
distraction defect with resulting obstruction or
remuneration for their work.
obliteration.12
The Urethral Stricture Amendment Panel was created in Urethral strictures or stenoses are treated endoscopically
2020 by the AUA. The Chair of the original guideline was or with urethroplasty. Endoscopic management is
appointed Chair of the amendment panel. The balance of performed by either urethral dilation or direct vision
the panel was composed of one member of the original internal urethrotomy (DVIU). There are a multitude of
panel and one content expert who was not a member of different urethroplasty techniques that can be generally
the original guideline panel. The outside expert was divided into tissue transfer-involved procedures and non-
approved by the PGC Chairs. The AUA conducted a tissue transfer-involved procedures. Anastomotic
thorough peer review process and the draft guideline urethroplasty does not involve tissue transfer and can be
document was distributed to 50 peer reviewers, 21 of performed in both a transecting and non-transecting
whom submitted a total of 67 comments. The Amendment manner. Excision and primary anastomosis urethroplasty
Panel reviewed and discussed all submitted comments involve transection and removal of the narrowed segment
and revised the draft as needed. Once finalized, the of urethra and corresponding spongiofibrosis with
guideline was submitted for approval to the PGC and anastomosis of the two healthy ends of the urethra and
Science and Quality Council. It was then submitted to corpus spongiosum. Non-transecting anastomotic
AUA Board of Directors for final approval. Panel members urethroplasty preserves the corpus spongiosum, thus
received no renumeration for their work.

allowing the strictured urethra to be excised and PATIENT REPORTED OUTCOMES

reanastomosed or incised longitudinally through the MEASURES
narrowed segment of the urethra and closed in a Heineke-
Mikulicz fashion. Patient reported measures (PRMs) help elucidate the
presence and severity of patient symptoms and bother
Techniques that involve tissue transfer can be and thus may serve as an important component of
categorized into single-stage and multi-stage procedures. urethral stricture diagnosis and management. While the
In single-stage procedures, the urethra is augmented in American Urological Association Symptom Index (AUASI)
caliber by transferring tissue in the form of a graft or flap. includes items assessing decreased urinary stream and
Multi-stage procedures use a graft as a urethral substitute incomplete bladder emptying, it does not identify other
for future tubularization. symptoms seen in patients with a urethral stricture, such
as urinary spraying and dysuria. 16 Therefore, there is a
Epidemiology
need for development of a standardized urethral stricture
Geographic setting, socioeconomic factors, and access to PRM that can be used to assess symptoms, degree of
healthcare can affect stricture etiology. In high income bother, and quality of life (QoL) impact. A more disease
countries, the most common etiology of urethral stricture specific standardized PRM will also allow for comparison
is idiopathic (41%) followed by iatrogenic (35%). Late of patient outcomes across research studies. Several
failure of hypospadias surgery and stricture resultant from have been developed in more recent years.17, 18
endoscopic manipulation (e.g., transurethral resection)
are common iatrogenic reasons. In comparison, trauma
DIAGNOSIS
(36%) is the most common cause in low- and middle- All patients being evaluated for LUTS should have a
income countries, reflecting higher rates of road traffic complete history and physical examination and urinalysis
injuries, less developed trauma systems, inadequate at a minimum. Decreased urinary stream, incomplete
roadway systems, and conceivably socioeconomic emptying, and other findings such as UTI should alert
factors leading to a higher prevalence of trauma-related clinicians to include urethral stricture in the differential
strictures.13-15 diagnosis. In the initial assessment of patients suspected
Strictures in the bulbar urethra are more common than of having a urethral stricture, a combination of PRMs to
other anatomic locations in males; however, certain assess symptoms, uroflowmetry to determine severity of
etiologies are closely associated with an anatomic obstruction, and ultrasound PVR volume to identify
segment of the urethra.13 For example, strictures related urinary retention may be used. Patients with symptomatic
to hypospadias and lichen sclerosus ([LS]; previously urethral stricture typically have a reduced peak flow
termed balanitis xerotica obliterans) are generally located rate.19, 20 Confirmation of a urethral stricture diagnosis is
in the penile urethra, while traumatic strictures and made with urethroscopy, retrograde urethrography
stenoses tend to be located in the bulbar and posterior (RUG), or ultrasound urethrography. In women,
urethra. videourodynamic studies can be used to diagnose
urethral strictures by demonstrating elevated detrusor
Preoperative Assessment voiding pressures and urethral obstruction on voiding
cystourethrography (VCUG).21, 22 Urethroscopy readily
PRESENTATION
identifies a urethral stricture but does not delineate the
Patients with urethral stricture most commonly present location and length of strictures. RUG, with or without
with decreased urinary stream and incomplete bladder VCUG, allows for identification of stricture location in the
emptying but may also demonstrate UTI, epididymitis, urethra, length of the stricture, and degree of lumen
rising post-void residual (PVR), or decreased force of narrowing.23, 24 All of these stricture characteristics are
ejaculation. Additionally, patients may present with important for subsequent treatment planning. Ultrasound
urinary spraying or dysuria.16 urethrography can be used to identify the location, length,
and severity of male urethral stricture.25 While ultrasound
urethrography is a promising technique, further studies
are needed to validate its value in clinical practice.
10

Preoperative assessment for definitive reconstruction POSTOPERATIVE CARE

should elicit details of the etiology, diagnostic information
A urinary catheter should be placed following urethral
about length and location of the stricture, and prior
stricture intervention to divert urine from the site of
treatments. In the case of PFUI, a detailed history should
intervention and prevent urinary extravasation. Either
document all associated injuries and angiographic
urethral catheter or suprapubic (SP) cystostomy is a
embolization of any pelvic vessels. The history should
viable option; a urethral catheter is thought to be optimal
assess preoperative sexual function and urinary
as it may serve as a stent around which the site of urethra
continence. Physical examination should include an
intervention can heal. The length of urinary
abdominal and genital exam, digital rectal exam, and
catheterization is widely variable, with a shorter
assessment of lower extremity mobility for operative
recommended time for endoscopic interventions than
positioning.
open urethral reconstruction.28
PATIENT SELECTION
Urethrography or voiding cystography is typically
Patient selection and proper surgical procedure choice performed two to three weeks following open urethral
are paramount to maximize the chance of successful reconstruction to assess for complete urethral healing.
outcome in the treatment of urethral stricture. The main Replacement of the urinary catheter is recommended in
factors to consider in decision making include stricture the setting of a persistent urethral leak to avoid tissue
etiology, location, and severity; prior treatment; inflammation, urinoma, abscess, and/or
comorbidity; and patient preference. As with any urethrocutaneous fistula. A urethral leak will heal in
operation, surgeons should consider a patient's goals, almost all circumstances with a longer duration of catheter
preferences, comorbidities, and fitness for surgery prior to drainage.29, 30
performing urethroplasty.26
COMPLICATIONS
OPERATIVE CONSIDERATIONS
Erectile dysfunction (ED), as measured by the
Before proceeding with surgical management of a urethral International Index of Erectile Function (IIEF) may occur
stricture, the physician should provide an appropriate transiently after male urethroplasty with resolution of
antibiotic to reduce surgical site infections. Preoperative nearly all reported symptoms approximately six months
urine cultures are recommended to guide antibiotic postoperatively.31-35 Meta-analysis has demonstrated the
choice, and active UTIs must be treated before urethral risk of new onset ED following anterior urethroplasty to be
stricture intervention. Prophylactic antibiotic choice and ~1%.36 Erectile function following urethroplasty for PFUI
duration should follow AUA Best Practice Policy does not appear to significantly change as a result of
Statement.27 To avoid bacterial resistance, antibiotics surgery. ED in this cohort may be related to the initial
should be discontinued after a single dose or within 24 pelvic trauma rather that the subsequent urethral
hours. Antibiotics can be extended in the setting of an reconstruction.37
active UTI or if there is an existing indwelling catheter.27 In
Ejaculatory dysfunction manifested as pooling of semen,
the setting of endoscopic urethral stricture management,
decreased ejaculatory force, ejaculatory discomfort, and
oral fluoroquinolones are more cost effective than
decreased semen volume has been reported by up to
intravenous cephalosporins.27 Antimicrobial prophylaxis
21% of men following bulbar urethroplasty. 38
is recommended at the time of urethral catheter removal
Urethroplasty technique may play a role in the occurrence
in patients with certain risk factors.27
of ejaculatory dysfunction but the exact etiology remains
Positioning of the extremities should be careful to avoid uncertain.39-41 Conversely, some patients, as measured
pressure on the calf muscles, peroneal nerve, and ulnar by the Men's Sexual Health Questionnaire, will notice an
nerve when using the lithotomy position. Use of improvement in ejaculatory function following bulbar
sequential compression devices is recommended to urethroplasty, particularly those with pre-operative
reduce deep venous thromboembolism and nerve ejaculatory dysfunction related to obstruction caused by
compression injuries. Perioperative parenteral deep the stricture.38 Data on ejaculatory function in men
venous thromboembolism prophylaxis is a consideration undergoing penile urethroplasty or urethroplasty for PFUI
in select circumstances for open reconstruction. is limited.
11

FOLLOW UP emptying to rule out occult retention should be done on all

patients.
Successful treatment for urethral stricture (endoscopic or
surgical) is most commonly defined as no further need for The basic laboratory examination includes a urinalysis
surgical intervention or instrumentation.42-54 Some studies and urine culture. A proper hematuria workup should be
use the absence of postoperative or post-procedural performed for patients with unevaluated hematuria, and
patient reported obstructive voiding symptoms and/or considered for patients with tobacco exposure given the
peak uroflow >15m/sec as a benchmark for successful high risk of bladder cancer in smokers.74 Urine culture
treatment.55-60 Additional measures of success that have may be indicated even in patients with a negative
been used alone or in combination include urethral urinalysis in order to detect lower levels of bacteria that
patency assessed by urethro-cystoscopy, absence of are clinically significant but not readily identifiable with a
recurrent stricture on urethrography, PVR urine <100mL, dipstick or on microscopic exam.
"unobstructed" flow curve shape on uroflowmetry,
absence of UTI, ability to pass a urethral catheter, and
patient-reported improvement in LUTS.61-65 Consensus 2. After performing a history, physical examination,
has not been reached on the optimal postoperative and urinalysis, clinicians may use a combination
surveillance protocol to identify stricture recurrence of patient reported measures, uroflowmetry, and
following urethral stricture treatment. ultrasound post-void residual assessment in the
initial evaluation of suspected urethral
stricture. (Clinical Principle)
Guideline Statements A number of self-report instruments, including the AUASI

and UDI-677 have been used to evaluate men and women
DIAGNOSIS for LUTS. Individual questions from these instruments
may be used to detect symptoms consistent with stricture
1. Clinicians should include urethral stricture in disease.
the differential diagnosis of patients who
present with decreased urinary stream, If symptoms and signs suggest the presence of a
incomplete emptying, dysuria, urinary tract stricture, noninvasive measures such as uroflowmetry
infection, and after rising post-void residual. may definitively delineate low flow, which is typically
(Moderate Recommendation; Evidence Level: considered to be <12 mL/second.19, 20 Similarly,
Grade C) ultrasonographic PVR measurement may detect poor
bladder emptying. The presence of voiding symptoms as
The physical examination should include an abdominal described above, in combination with reduced peak flow
and pelvic examination noting masses, tenderness, and rate for age, place patients at higher probability for
presence of hernias. The pelvic examination should urethral stricture, therefore indicating definitive evaluation
include palpation of the external genitalia, bladder base in such as cystoscopy, RUG, VCUG, or ultrasound
females, and urethra in both sexes. The pelvic floor urethrography.
muscles in both sexes should be palpated for locations of
tenderness and trigger points. The pelvic support for the
bladder, urethra, vagina, and rectum should be 3. Clinicians should use urethro-cystoscopy,
documented. A focused evaluation to rule out vaginitis, retrograde urethrography, voiding
urethritis, tender prostate, urethral diverticulum, or other cystourethrography, or ultrasound urethography
potential sources of pain or infection is important. For a to make a diagnosis of urethral stricture.
more detailed discussion, please see Weiss 2001.73 A trial (Moderate Recommendation; Evidence Level:
of antibiotic therapy is appropriate when infection is Grade C)
suspected; if symptoms resolve a course of antibiotic Endoscopy and/or radiological imaging of the urethra is
suppression may be considered to allow for full recovery. essential for confirmation of the diagnosis, assessment of
A brief neurological exam to rule out an occult neurologic stricture severity (e.g., staging), and procedure selection.
problem and an evaluation for incomplete bladder History, physical examination, and adjunctive measures
12

(Statements 1 and 2) cannot definitively confirm a urethral U LTRASOUND U RETHROGRAPHY

stricture. Urethroscopy identifies and localizes urethral
Ultrasound urethrography may serve to diagnose the
stricture and allows evaluation of the distal caliber, but the
presence of urethral stricture as well as describe the
length of the stricture and the urethra proximal to the
location, length, and severity of narrowing of strictures. It
urethral stricture cannot be assessed in most cases.
has a hgh sensitivity and specificity in the male anterior
When flexible cystoscopy does not allow visual
urethra but shares the drawbacks of RUG, including
assessment proximal to the urethral stricture, small
patient discomfort and dependence on a skilled
caliber cystoscopy with a ureteroscope or flexible
ultrasonographer.25 One study in women reported that the
hysteroscope can be useful adjuncts. MRI can provide
technique appeared to identify and characterize female
important detail in select cases (i.e., PFUI, diverticulum,
urethral strictures adequately.81 Some advocate the use
fistula, cancer). In women, imaging of the urinary tract
of urethral sonography (ultrasound urethrography) to
using endourethral MRI, ultrasonogram, and CT scan can
define the extent of spongiofibrosis and absolute length of
confirm presence of periurethral fibrosis76 and exclude
the urethral stricture,82-95 although this is not strictly
associated abnormalities.71
required and is not used by a majority of stricture
R ETROGRADE U RETHROGRAPHY experts.96
RUG, with or without VCUG, remains the study of choice
for delineation of stricture length, location, and severity in
4. Clinicians planning non-urgent intervention for a
men.23, 24, 78 However, the image quality and accuracy of
known stricture should determine the length and
RUG is operator-dependent; surgical planning should be
location of the urethral stricture. (Expert
based on high quality images generated by experienced
Opinion)
practitioners or the surgeon him/herself.79
Determination of urethral stricture length and location
The modestly invasive nature of RUG reflects the
allows the patient and urologist to engage in an informed
potential risks, including patient discomfort, UTI,
discussion about treatment options, perioperative
hematuria, and contrast extravasation. UTI is rare and
expectations, and expected outcomes following urethral
contrast extravasation is very rare in expert hands.
stricture therapy. In addition, preoperative planning
Exposure to the contrast puts the patient at risk for a
permits operative and anesthetic planning.
contrast reaction, should there be an allergy. The risk is
very low in the absence of inadvertent extravasation and
may be mitigated by pre-medication with oral 5. Surgeons may utilize urethral endoscopic
corticosteroids and histamine blockers. Complete or near management (e.g., urethral dilation or direct
complete occlusion of the urethra may make the visual internal urethrotomy) or immediate
assessment of the urethra proximal to the stricture suprapubic cystostomy for urgent management
difficult. In this instance, RUG may be combined with of urethral stricture, such as discovery of
antegrade VCUG or other methods to define the extent of symptomatic urinary retention or need for
the stricture. catheterization prior to another surgical
V OIDING C YSTOURETHROGRAPHY procedure. (Expert Opinion)
VCUG performed by passing a small catheter proximal to When urethral strictures are identified at the time of
the stricture, by retrograde filling of the bladder during catheter placement for another surgical procedure,
RUG, or by antegrade filling via a SP tube, allows assessment of the need for catheterization should be
visualization of the urethra but is not always sufficient to made. Urethral catheter placement may not be required
completely delineate the distal extent of an urethral for surgical procedures that are short in duration. If
stricture. When used in conjunction with urodynamics to catheterization is deemed necessary, the primary
asses complex voiding dysfunction, elevated detrusor consideration should be safe urinary drainage. Urethral
voiding pressures and urethral narrowing on VCUG strictures may be dilated in this setting to allow catheter
indicate a clinically significant urethral stricture or other insertion, and dilation over a guidewire is recommended
obstructive process.80 to prevent false passage formation or rectal injury.
13

Alternatively, internal urethrotomy may be performed, Short bulbar urethral strictures may be treated by dilation,
particularly if the stricture is too dense to be adequately DVIU, or urethroplasty. Urethral dilation and DVIU have
dilated. SP cystotomy may also be performed to provide similar long-term outcomes in short strictures, with
urinary drainage at the time of surgery if these initial success ranging from 35-70%.100-102 The success of
maneuvers are unsuccessful, or when subsequent endoscopic treatment depends on the location and length
definitive treatment for urethral stricture is planned in the of the stricture, with the highest success rates found in
near future. those with bulbar urethral strictures <1cm.103-105
Conversely, success rates for dilation or DVIU of
strictures >2cm are very low.101, 105 Drug coated balloons
6. Surgeons may place a suprapubic cystostomy to have not been assessed in RCTs for first-time treatment
promote “urethral rest” prior to definitive of anterior urethral stricture.
urethroplasty in patients dependent on an
Urethroplasty has a higher long-term success rate than
indwelling urethral catheter or intermittent self-
endoscopic treatment, ranging from 80-95%.
dilation. (Conditional Recommendation;
Urethroplasty may be offered as the initial treatment for a
short bulbar urethral stricture, but the higher success rate
Proper evaluation of a urethral stricture may require a of this treatment compared to endoscopic treatment must
period of “urethral rest,” without urethral instrumentation be weighed against the increased anesthesia
to determine the true severity of the stricture including its requirement and higher morbidity of urethroplasty.
degree of narrowing. Men with a urethral stricture who
In patients with a short (<2cm) bulbar urethral stricture,
have been managed with either an indwelling urethral
non-transecting substitution urethroplasty results in fewer
catheter or self-dilation should generally undergo SP
penile complications (e.g., poor glans filling, penile
cystostomy placement prior to imaging. Experts agree
shortening) compared to transecting urethroplasty.106
that urethral rest via SP cystostomy promotes a safe
However, there appears to be no difference in ED
transition strategy for patients with unstable strictures
measured by IIEF at 12 months with transecting
being referred for urethroplasty. Tissue recovery and
compared to non-transecting urethroplasty.106-109
stricture maturation can be expected in 4-6 weeks, which
allows the stricture to mature and enables accurate
radiographic and/or endoscopic identification in
8. Surgeons may perform either dilation or direct
preparation for definitive management. If a patient can
visual internal urethrotomy when performing
forgo clean intermittent catheterization (CIC) without
endoscopic treatment of a urethral stricture.
acute urinary retention, a SP tube may be omitted during
(Conditional Recommendation; Evidence Level:
urethral rest.97-99 This allows the full length of the stricture
Grade C)
to develop and accurate determination of definitive
treatment options to be made. This is thought to maximize Dilation and DVIU have similar success and complication
success by not underestimating the length of stricture and rates and can be used interchangeably for the initial
degree of spongiofibrosis. A similar period of observation treatment of short urethral strictures. Few studies exist
is recommended before reassessing a stricture after that compare different methods of performing DVIU, but
failure or dilation or DVIU. cold knife and laser incision of the stricture scar appear to
have similar success rates and may be used
interchangeably.110, 111 Other methods of incision may be
DILATION/INTERNAL used experimentally, such as PlasmaKinetic incision.61 A
small experimental study suggests that holmium: YAG
URETHROTOMY/URETHROPLASTY laser urethrotomy may have higher success rates in
7. Surgeons may offer urethral dilation, direct iatrogenic strictures.110
visual internal urethrotomy, or urethroplasty for Clinicians may endoscopically inject pharmacological
the initial treatment of a short (<2cm) bulbar agents into a urethral stricture at the time of DVIU to
urethral stricture. (Conditional Recommendation; reduce risk of stricture recurrence. The few studies
Evidence Level: Grade C) available showed a generally consistent lower stricture
14

recurrence rate when steroids were added to DVIU, dilation or direct visual internal
although the findings did not reach statistical significance urethrotomy. (Moderate Recommendation;
and follow up was relatively short.112, 113 Mitomycin C Evidence Level: Grade C)
injected at the time of DVIU has also been shown to
11 b. Surgeons may offer urethral dilation, or direct
reduce stricture recurrence rate, although data is limited
visual internal urethrotomy, combined with drug-
regarding long term follow up.114
coated balloons, for recurrent bulbar urethral
strictures <3cm in length. (Conditional
Recommendation; Evidence Level: Grade B)
9. Surgeons may safely remove the urethral catheter
within 72 hours following uncomplicated dilation Urethroplasty, even in the setting of failed endoscopic
or direct visual internal urethrotomy. (Conditional management, offers success rates in the range of 80-
Recommendation; Evidence Level: Grade C) 90%.127 Urethral strictures that have been previously
treated with dilation or DVIU are unlikely to be
The reported length of catheterization after dilation or
successfully treated with another endoscopic
DVIU is highly variable in the literature, ranging from one
procedure,117 with failure rates of >80%. 128 Repeated
to eight days.101, 105, 110, 115-119 There is no evidence that
endoscopic treatment may cause longer strictures and
leaving the catheter longer than 72 hours improves safety
may increase the complexity of subsequent
or outcome, and catheters may be removed after 24-72
urethroplasty.129 In patients who are unable to undergo,
hours. Catheters may be left in longer for patient
or who prefer to avoid, urethroplasty, repeated
convenience or if in the surgeon’s judgment early removal
endoscopic procedures or intermittent self-catheterization
will increase the risk of complications.
may be considered as palliative measures.
The recent OPEN130 and ROBUST III131 trials provide new
10. In patients who are not candidates for insights into the evolving role for endoscopic
urethroplasty, clinicians may recommend self- management in the treatment of recurrent bulbar urethral
catheterization after direct visual internal stricture. If replicated in additional patient populations at
urethrotomy to maintain temporary urethral longer follow-up, the two RCTs taken together suggest
patency. (Conditional Recommendation; that future patients will face a wider range of treatment
Evidence Level: Grade C) options for recurrent bulbar urethral stricture and that a
Studies using varying self-catheterization schedules after shared decision-making approach to counseling may be
DVIU, ranging from daily to weekly, have demonstrated advisable.
that stricture recurrence rates were significantly lower Using a patient-centered approach, the multicenter OPEN
among patients performing self-catheterization (RR: 0.51; pragmatic trial used patient reported voiding symptoms as
95% CI: 0.32-0.81; p = 0.004).116, 120-123 The optimal the primary outcome in a randomized superiority
protocol for DVIU plus self-catheterization remains comparison of endoscopic urethrotomy versus open
uncertain. However, data suggests that performing self- urethroplasty in men with recurrent bulbar urethral
catheterization for greater than 4 months after DVIU stricture <2cm in length. There was not a statistically
reduced recurrence rates compared to performing self- significant difference in urethral stricture specific PRMs
catheterization for less than 3 months.116, 120-125 Even between the two groups over the 24-month study period:
though the risk of UTI does not appear to be increased in impact on daily activities and satisfaction with sexual
patients performing self-catheterization after DVIU, the function between the two groups was equivalent.
ability to continue with self-catheterization may be limited Notably, participants who underwent urethroplasty were
in some patients by manual dexterity or pain with at a 48% reduced risk for reintervention (HR: 0.52; 95%
catheterization.116, 125, 126 CI: 0.31-0.89).132 Of those who received urethrotomy,
39% experienced a recurrence versus 19% in the
urethroplasty group (p=0.001). Furthermore, participants
11 a. Surgeons should offer urethroplasty, instead of in the urethroplasty group had 2.6 times greater odds of
repeated endoscopic management for recurrent experiencing an improvement in their maximum flow rate
anterior urethral strictures following failed
15

at 12-24 months than the participants in the urethrotomy pass a flexible cystoscope) and repeat intervention,
group (OR: 2.6; 95% CI: 1.1–6.1; p= 0.024).130, 132 rigorous and ascertainable endpoints that value freedom
from reintervention over symptoms.
The ROBUST III multicenter RCT used urethral patency
at 6 months and freedom from retreatment at 1 year as
the primary and secondary outcomes in a comparison of
12. Surgeons who do not perform urethroplasty
endoscopic treatment of the stricture combined with
should refer patients to surgeons with
paclitaxel-coated urethral balloon versus DVIU/dilation in
expertise. (Expert Opinion)
patients with recurrent anterior urethral strictures <3cm in
length. Those who underwent endoscopic treatment When evaluating a patient with a recurrent urethral
combined with the drug-coated balloon had improved stricture, a physician who does not perform urethroplasty
freedom from intervention at 1 year compared to should consider referral to a surgeon with experience in
DVIU/dilation alone (83.2% versus 21.7%).131 The 3-year this technique due to the higher rate of successful
outcomes for the same drug-coated balloon from the treatment compared to repeat endoscopic management.
Robust I trial demonstrated a 67% functional success.133 The relationship between surgical volume and quality is
an area for future investigation. There are cases series
Although the device is approved by the FDA for anterior
that suggest that better outcomes following urethroplasty
urethral strictures, because the trial was not powered to
are associated with greater surgeon experience.134
assess results in the subset of participants with penile
urethra strictures, which constituted only 10% of the
overall cohort, this panel’s recommendation for use of 13. Surgeons may initially treat meatal or fossa
drug-coated balloons is restricted to recurrent bulbar navicularis strictures with either dilation or
urethral strictures. Furthermore, the efficacy of repeated meatotomy. (Clinical Principle)
use of the drug coated balloon has not been ascertained
and is not recommended. Most side effects were similar First time presentation of an uncomplicated urethral
across treatment arms in ROBUST III, except hematuria stricture confined to the meatus or fossa navicularis can
and dysuria, which were more common after drug coated be treated with simple dilation or meatotomy, with or
balloon treatment (11% versus 2% for both events). without guidewire placement, as long as it is not
Significant levels of paclitaxel were measured in semen; associated with previous hypospadias repair, prior failed
it is recommended that men receiving this treatment endoscopic manipulation, previous urethroplasty, or LS.49
utilize contraception through 6 months posttreatment if Strictures related to hypospadias and LS require unique
their partner has child-bearing potential.131 treatment strategies.135 However, in the setting of LS
The findings of these two studies, highlight the importance there is some evidence that extended meatotomy in
of a patient centered approach to recurrent urethral conjunction with high-dose topical steroids may decrease
strictures, challenges inherent in the evidence reviewed the risk of recurrence as compared to meatotomy
in support of this guideline, and opportunities for future alone.136 Additionally, no evidence exists on the optimal
directions. As individual studies without replication, both caliber of dilation or the need to implement a post dilation
OPEN and ROBUST III are at greater risk for bias. The CIC regimen to reduce stricture recurrence.
design of ROBUST III, with features of an efficacy study
in a highly selected population, may not easily generalize
to anterior urethral stricture patients broadly. In contrast, 14. Surgeons should offer urethroplasty to patients
the pragmatic design of OPEN and performance at 50 with recurrent meatal or fossa navicularis
sites across the UK National Health Service should strictures. (Moderate Recommendation; Evidence
assure greater generalizability. Further, each trial used a Level: Grade C)
different conceptual choice of primary outcome. The Meatal and fossa navicularis strictures refractory to
investigators of the OPEN study emphasized that endoscopic procedures are unlikely to respond to further
symptoms are likely to be the central concern for patients endoscopic treatments.100, 101, 105, 117, 119, 137, 138
with bulbar urethral strictures and the reason why they Furthermore, urethroplasty is the best option for
look for treatment. ROBUST III used patency (ability to completely obliterated strictures or strictures associated
16

with hypospadias or LS. Some patients may opt for repeat urethroplasty at the time of diagnosis, avoiding repeated
endoscopic treatments or intermittent self-dilation in lieu endoscopic treatments. When compared to bulbar
of more definitive treatment such as urethroplasty. Similar urethral strictures, penile urethral strictures are more
to other types of stricture exact delineation of length and likely to require tissue transfer and/or a staged
etiology is important for guiding treatment. approach.143, 150
Urologists have a variety of options at their disposal for When performing single-stage urethroplasty, penile
the surgical treatment of meatal and fossa strictures, fasciocutaneous flaps and oral mucosal grafts have been
including meatoplasty, extended meatotomy, and several used in differing configurations.49, 55, 151-157 Success rates
variations of urethroplasty. It is important to consider both in penile urethroplasty for properly selected patients
aesthetic and functional outcomes when reconstructing appear similar regardless of tissue and technique
strictures involving the glanular urethra. Simple used.154, 158, 159
reconfiguration of the meatus can be performed using a
variety of techniques but is best suited to non-obliterated
strictures confined to the meatus.135 In this setting, there 16. Surgeons should offer urethroplasty as the initial
is an approximate 75% chance of success.135 Meatotomy treatment for patients with long (≥2cm) bulbar
and extended meatotomy have also been employed with urethral strictures given the low success rate of
success rates up to 87%.49, 135 direct visual internal urethrotomy or dilation.
(Moderate Recommendation; Evidence Level:
Reconstruction of the fossa navicularis can be achieved
Grade C)
using a variety of techniques and tissue sources without
possible negative cosmetic and functional consequences Longer strictures are less responsive to endoscopic
of meatotomy. One-stage urethroplasty for recurrent treatment, with success rates of only 20% for strictures
meatal and fossa navicularis strictures has been reported >4cm in the bulbar urethra.102 The success rate for buccal
with acceptable outcomes.49, 139-142 Strictures related to LS mucosa graft urethroplasty for strictures of this length is
are less likely to be reconstructed successfully using greater than 80%.43, 160, 161
genital skin transfer given that LS is a condition of the Given the low efficacy of endoscopic treatment,
genital skin.143 In these instances, the success of oral urethroplasty should be offered to patients with long
mucosal grafts has been reported between 83%- urethral strictures. Urethroplasty may be performed using
100%.139, 140, 144 a variety of techniques based on the experience of the
In the setting of failed hypospadias surgery, no single surgeon, most often through substitution or augmentation
technique can be recommended, although the absence of of the narrowed segment of the urethra.
adjacent skin for transfer increases the likelihood of
requiring a staged oral mucosa graft urethroplasty.145-149
17. Surgeons may reconstruct long multi-segment
strictures with one-stage or multi-stage
15. Surgeons should offer urethroplasty to patients techniques using oral mucosal grafts, penile
with penile urethral strictures given the expected fasciocutaneous flaps, or a combination of these
high recurrence rates with endoscopic techniques. (Moderate Recommendation;
treatments. (Moderate Recommendation; Evidence Level: Grade C)
Evidence Level: Grade C) Multi-segment strictures (frequently referred to as
Strictures involving the penile urethra are more likely to panurethral strictures) are most commonly defined as
be related to hypospadias, LS, or iatrogenic etiologies strictures >10cm spanning long segments of both the
when compared to strictures of the bulbar urethra. These penile and bulbar urethra. These strictures are particularly
strictures are unlikely to respond to dilation or complex to treat surgically.47 Several treatment options
urethrotomy, except in select cases of previously exist including long-term endoscopic management,
untreated short strictures.100, 101, 105, 117, 119 Given the low urethroplasty, or perineal urethrostomy. Clinicians should
likelihood of success with endoscopic treatments, most be aware that panurethral strictures are very unlikely to
patients with penile urethral strictures should be offered be treated successfully with endoscopic means, which
17

offer only temporary relief of obstruction.26, 100, 101, 105, 117, Table 3: Considerations in Decision Making for
119, 137 However, urethroplasty in these instances is also
Perineal Urethrostomy
more complicated, time-consuming, and has a higher Recurrent strictures failing prior reconstructions
failure rate as compared to urethroplasty for less
complicated strictures.47, 162, 163 Thus, some patients may Accustomed to seated voiding
choose repeat endoscopic treatments, with or without a Buried penis
self-dilation protocol, or a perineal urethrostomy, in order
to avoid complex urethral reconstructive surgery. Multiple comorbidities
Reconstruction of panurethral strictures should be Complex penile strictures, including reoperative

addressed with all of the tools in the reconstructive hypospadias
armamentarium including fasciocutaneous flaps, oral Lichen Sclerosus
mucosal grafts, or other ancillary tissue sources, and may
require a combination of these techniques.47, 156, 164 These Poor access to urologic care
labor intensive and technically challenging surgeries are Urinary continence status
best performed at established high volume reconstructive
centers. Several tissue sources have been reported
including oral mucosal grafts, various skin grafts, and Patients undergoing perineal urethrostomy have reported
genital fasciocutaneous flaps.47, 156, 164, 165 Regardless of high QoL, although surgical revision may be necessary to
technique and combinations, success rates appear maintain patency over long term follow up.172, 173
similar in all of these small series. Superior efficacy of Successful treatment with perineal urethrostomy has
“double graft” procedures has not yet been demonstrated been reported in both traumatic and LS strictures.172-174
and these techniques are typically applied to select There are no data demonstrating that a specific surgical
instances of urethral obliteration.29, 45, 55, 63, 144, 166-168 technique is associated with a higher patient QoL or long
Staged procedures may offer a conservative approach term patency rate.
suited to the most complex strictures such as those
related to failed hypospadias surgery.145-149, 169
19 a. Surgeons should use oral mucosa as the first
choice when using grafts for urethroplasty.
18 a. Surgeons may offer perineal urethrostomy as a (Expert Opinion)
long-term treatment option to patients as an
19 b. Surgeons may use either buccal or lingual
alternative to urethroplasty. (Conditional
mucosal grafts as equivalent alternatives. (Strong
Recommendation; Evidence Level: Grade A)
18 b. Surgeons should offer perineal urethrostomy
Oral mucosa is the preferred graft for substitution
as a long-term treatment option to patients as an
urethroplasty. Patient satisfaction is higher for oral
alternative to urethroplasty in patient populations
mucosa due to less post-void dribbling and penile skin
at high risk for failure of urethral reconstruction.
problems.40, 60
(Expert Opinion)
Oral mucosa may be harvested from the inner cheeks
Perineal urethrostomy can be used as a staged or
(buccal), which provide the largest graft area, the
permanent option for patients with anterior urethral
undersurface of the tongue (lingual), or the inner lower lip
strictures in order to establish unobstructed voiding and
(labial). Lingual mucosa is thinner than buccal mucosa,
improve QoL.170, 171 Reasons to perform perineal
and thus may provide an advantage in reconstructive
urethrostomy (Table 3) include recurrent or primary
procedures of the distal urethra and meatus by causing
complex anterior stricture, medical co-morbidities
less restriction of the urethral lumen. Harvest of buccal
precluding extended operative time, extensive LS,
mucosa from the inner cheek results in fewer
numerous failed attempts at urethroplasty, and patient
complications and better outcomes as compared to a
choice.49, 172-174
lower lip donor site.175 A meta-analysis of 12 published
studies found no difference in the success rate of buccal
18

and lingual mucosal grafts when the donor sites were by corpus spongiosum of glans). When no alternative
compared (RR:1.03; 95% CI:0.96-1.10).176 The same exists, a tubularized flap can be performed with results
meta-analysis found no significant difference between that are inferior to onlay flaps.183, 184 Currently, available
mucosal sites for risk of stricture complications or risk of alternatives include combined tissue transfer (e.g., a
fistula/wound dehiscence. However, buccal mucosal dorsal buccal graft combined with a ventral skin flap in a
grafts carried a higher risk of donor site swelling, oral single stage), combined dorsal and ventral grafts (e.g., a
numbness, and difficulty with mouth opening, while dorsal graft in the technique of Asopa and a ventral onlay
patients undergoing lingual mucosal grafts demonstrated graft), or staged urethroplasty with local skin flaps or oral
higher risk of difficulty with speech and difficulty with mucosa grafts.
tongue protrusion.
When harvesting buccal mucosa from the inner cheek,
22. Surgeons should not use hair-bearing skin for
the donor site may safely be left open to heal by
substitution urethroplasty. (Clinical Principle)
secondary intention or closed primarily.177 A meta-
analysis of five RCTs found no difference between The use of hair-bearing skin for substitution urethroplasty
closure and non-closure procedures when focusing on may result in urethral calculi, recurrent UTI and a
oral pain, need for secondary oral procedures, cosmetic restricted urinary stream due to hair obstructing the
defects, oral numbness, salivary problems, or impaired lumen, and therefore should be avoided except in rare
mouth opening.178 Ultimately the decision to close the cases where no alternative exists.185 Intraurethral hair
donor site primarily or leave it open is at the discretion of should be suspected in patients who report these
the surgeon; large grafts required for staged urethroplasty symptoms and have a history of prior tubularized
often create defects that cannot be closed. urethroplasty or surgery for proximal hypospadias, in
which scrotal skin may have been incorporated into the
repair and demonstrate later hair growth.
20. Surgeons should not perform substitution
urethroplasty with allograft, xenograft, or
synthetic materials except under experimental URETHRAL RECONSTRUCTION
protocols. (Expert Opinion)
AFTER PELVIC FRACTURE
Use of non-autologous grafts may be indicated in the
patient who has failed a prior urethroplasty and has no
URETHRAL INJURY
tissue available for reoperative substitution urethroplasty. 23. Clinicians should use retrograde urethrography
However, experience to date is limited and the long term with voiding cystourethrogram and/or retrograde
success rates are unknown.53 179-182 Such patients should + antegrade cystoscopy for preoperative
be considered for referral to a center involved in clinical planning of delayed urethroplasty after pelvic
trials using allograft, xenograft, engineered or synthetic fracture urethral injury. (Moderate
materials. Recommendation; Evidence Level: Grade C)
Pre-operative evaluation of the distraction defect after
21. Surgeons should not perform a single-stage PFUI should include RUG, VCUG, and/or retrograde
tubularized graft urethroplasty. (Expert Opinion) urethroscopy. The VCUG may include a static cystogram
to determine the competency of the bladder neck
Tubularized urethroplasty consists of a technique in which mechanism and the level of the bladder neck in relation to
a graft or flap is rolled into a tube over a catheter to the symphysis pubis. Other adjunctive studies may
completely replace a segment of urethra. This approach, include antegrade cystoscopy, with or without
when attempted in a single stage, has a high risk of fluoroscopy, and pelvic CT or MRI to assess the proximal
restenosis and should be avoided. This is distinct from a extent of the injury, degree of malalignment of the urethra,
tubularized graft that is supported in its entirety by a and length of the defect.
suitable graft bed (e.g., 1-stage tubularized buccal
mucosa graft of the fossa navicularis urethra supported
19

24. Surgeons should perform delayed urethroplasty FEMALE URETHRAL

instead of delayed endoscopic procedures after
urethral obstruction/obliteration due to pelvic RECONSTRUCTION
fracture urethral injury. (Expert Opinion) 26. Surgeons may reconstruct female urethral
The acute treatment of PFUI includes endoscopic primary strictures using oral mucosal grafts, vaginal
catheter realignment or insertion of a SP tube. The flaps, or a combination of these techniques.
resulting distraction defect, stenosis, or obliteration (Moderate Recommendation; Evidence Level:
should be managed with delayed perineal anastomotic Grade C)
urethroplasty. Repeated endoscopic maneuvers including Given the low efficacy of endoscopic treatment,
CIC should be avoided because they are not successful urethroplasty should be offered to patients with female
in the majority of PFUI, increase patient morbidity, and urethral strictures.71 Urethroplasty may be performed
may delay the time to anastomotic reconstruction. using a variety of techniques based on the experience of
Clinicians should avoid blind "cut to the light" procedures the surgeon. Multiple studies have demonstrated similar
in the obliterated PFUI since they are rarely successful in outcomes for oral mucosa grafts (dorsal and ventral),
long term follow up. vaginal flaps, or a combination of these techniques, with
Anastomotic reconstruction is performed through a success rates between 69-95%.71, 72, 187-191
perineal approach. Excision of the scar tissue and wide
spatulation of the anastomosis is required. Several
methods to gain urethral length and reduce tension can BLADDER NECK CONTRACTURE/
be employed when necessary including mobilization of
VESICOURETHRAL STENOSIS
the bulbar urethra, crural separation, inferior pubectomy,
and supracrural rerouting, but in most cases the latter two 27. Surgeons may perform a dilation, bladder neck
maneuvers are not required. In rare cases, trans incision, or transurethral resection for bladder
abdominal or transpubic techniques may be required. In neck contracture after endoscopic prostate
order to potentially decrease the potential for vascular procedure. (Expert Opinion)
compromise to the urethra, a bulbar artery sparing
Treatment of bladder neck contractures following
approach has been described. No comparative study has
endoscopic prostate procedures can be performed with
yet shown any definitive benefit. Clinicians should refer
either a bladder neck incision or bladder neck resection
patients to appropriate tertiary care centers for
depending on surgeon preference, with comparable
reconstruction when necessary.
outcomes expected. Repeat endoscopic treatment may
be necessary for successful outcomes. No studies exist
that compare the different treatment strategies for bladder
25. Definitive urethral reconstruction for pelvic
neck contractures after endoscopic prostate procedures.
fracture urethral injury should be planned only
after major injuries stabilize and patients can be
safely positioned for urethroplasty. (Expert
28. Surgeons may perform a dilation, vesicourethral
Opinion)
incision, or transurethral resection for post-
The timing of urethral reconstruction in PFUI is highly prostatectomy vesicourethral anastomotic
dependent on patient factors. No optimal time to perform stenosis. (Conditional Recommendation;
urethral reconstruction has been established, with studies Evidence Level: Grade C)
reporting a wide range of times from 6 weeks to 4
Treatment of first-time vesicourethral anastomotic
years.186 Reconstruction should occur when patient
stenosis is successful in about 50-80% of cases, with all
factors allow the surgery to be performed, usually within
techniques having similar success rates.192-196 Success
3 to 6 months after the trauma. Patient positioning in the
appears to be lower in cases with prior pelvic radiation;
lithotomy (standard, high, or exaggerated) may be limited
however, prospective cohort studies including radiated
until orthopedic and lower extremity soft tissues injuries
and nonradiated patients are lacking. Repeat endoscopic
have resolved.
treatment may be necessary for successful treatment.
20

There is conflicting data about the utility of Mitomycin-C Bladder function must be considered prior to urethroplasty
for the treatment of recurrent vesicourethral stenosis, with as significant underlying detrusor dysfunction it may alter
further study necessary to validate its use.197, 198 Patients the course of treatment. It is unclear if anterior
should be made aware of the risk of incontinence after urethroplasty in this setting has higher rates of
any of these procedures. complications, stricture recurrence, or reoperation when
compared to men with anterior urethral stricture and intact
bladder function.204, 205 There is some evidence to suggest
29. Surgeons may perform robotic or open that urethral reconstruction, if offered at an early stage in
reconstruction for recalcitrant stenosis of the men with stricture and NBG, can achieve outcomes
bladder neck or post-prostatectomy comparable to men without NGB.204 It is not definitively
vesicourethral anastomotic known if resumption of CIC following anterior
stenosis. (Conditional Recommendation; urethroplasty impacts the risk of stricture recurrence.
The treatment of recalcitrant vesicourethral anastomotic
stenosis (VUAS) or bladder neck contracture must be LICHEN SCLEROSUS
tailored to the preferences of the patient, taking into
LS is a chronic inflammatory, scar forming dermatologic
consideration prior radiotherapy and the degree of urinary
disease that predominately affects the genitalia. In
incontinence. Reconstruction is challenging and may
women, urethral stricture is not a common feature of
cause significant urinary incontinence requiring
LS.206 In men, LS has a wide spectrum of disease
subsequent artificial urinary sphincter implantation. VUAS
presentation and severity, and thus warrants particular
or bladder neck reconstruction can be performed
attention from urologists. Patients with LS may present
robotically or open. Robotic-assisted reconstruction
with penile skin scarring, adhesions to the glans, and is a
patency rates range from 72.7-75%.199, 200 In patients who
frequent contributor to the development of acquired
were preoperatively continent, 82% were continent post-
buried penis. Additionally, LS is capable of malignant
operatively.199 Open VUAS or bladder neck
transformation, progressing to squamous cell carcinoma
reconstruction can be performed retropubically or
in 2-8% of patients.207, 208 This is important, in that male
perineally with patency rates ranging from 70-100%.201-203
patients presenting with acquired buried penis also have
In patients continent of urine pre-operatively who had a
concomitant urethral strictures in 31-47% of cases,
retropubic approach, 10% were incontinent post-
thereby requiring careful evaluation and management.209-
operatively, while those who had a perineal reconstruction 211
had an 83.3% incontinence rate post-operatively.201, 202
Success rates are lower after radiation. Urethroplasty is challenging in this population, as patients
are more likely to be active tobacco smokers, have a
For the patient who does not desire urethroplasty, repeat
higher body mass index, hypertension, diabetes mellitus,
urethral dilation, incision, or resection of the stenosis is
coronary artery disease, and have longer urethral
appropriate. Intermittent self-dilation with a catheter may
strictures compared to non-LS urethral strictures.212-214
be used to prolong the time between operative
Urethroplasty often requires multiple oral mucosa grafts
interventions. SP diversion is an alternative.
to reconstruct long-segment strictures, often with a lower
success rate compared to non-LS urethral strictures, and
thus a comprehensive discussion of the various
SPECIAL CIRCUMSTANCES management strategies is warranted.
30. In men who require chronic self-catheterization
(e.g., neurogenic bladder), surgeons may offer
31. Clinicians may perform biopsy for suspected
urethroplasty as a treatment option for urethral
lichen sclerosus and must perform biopsy if
stricture causing difficulty with intermittent self-
urethral cancer is suspected. (Clinical Principle)
catheterization. (Expert Opinion)
The external manifestations of LS in males can range in
In men with neurogenic bladder (NGB) urethral pathology
severity from mild to aggressive. It is most commonly
may include stricture, diverticulum, fistula, and erosion.
21

found in the genital region and may be associated with length, strictures related to LS, hypospadias, or a repair
urethral strictures.207, 215, 216 LS may mimic many other involving a flap or graft.134, 154, 162, 163, 221-229
skin diseases; therefore, biopsy is the best method for
Surgeons can use a number of diagnostic tests to detect
definitive diagnosis. The rate of squamous cell carcinoma
or screen for stricture recurrence following open or
in male patients with LS has been reported to be 2-8.6%,
endoscopic treatment (see Statements 1 and 2); however,
further indicating the need for biopsy in selected cases
the use of, or combination of, urethrocystoscopy, urethral
both to confirm the diagnosis as well as to exclude
ultrasound, or RUG appears to provide the most definitive
malignant or premalignant changes.208, 216-218
confirmation of stricture recurrence.82, 84, 85, 87-90, 230, 231 No
specific urethral lumen diameter, determined
endoscopically or radiographically, has been shown to be
32. In lichen sclerosus-proven urethral stricture,
diagnostic of a stricture recurrence.
surgeons should not use genital skin for
reconstruction. (Strong Recommendation; Although stents are not currently recommended for the
Evidence Level: Grade B) treatment of urethral stricture. Patients treated with a
urethral stent after dilation or internal urethrotomy should
Goals of management of LS should be to alleviate
be monitored for recurrent stricture and complications.
symptoms, prevent and treat urethral stricture disease
Recurrent strictures have been reported in new urethral
and prevent and detect malignant transformation.207
regions outside of the stent placement as well as within
Treatment of genital skin LS reduces symptoms, such as the stent treated region.232-234 Patients with completely
skin itching and bleeding, and may serve to prevent obstructed stents may require open urethroplasty and
meatus stenosis and progression to extensive stricture of removal of the stent.233 Other stent complications include
the penile urethra. Current therapies rely heavily on stent-induced hematuria, urethral pain, urinary
topical moderate- to high-potency steroid creams, such as incontinence, and chronic UTI.128, 232-236 Complications
clobetasol or mometasone creams. Calcineurin inhibitors can occur at any time point after stent placement, so long-
such as tacrolimus have been shown to cause regression term monitoring with cystoscopy or urethral imaging is
in external skin manifestations.207 advised. Stents do not need to be prophylactically
Reconstruction of anterior urethral strictures associated removed and should be followed conservatively unless
with LS should proceed according to principles of anterior associated with significant urethral or voiding symptoms.
urthroplasty, with the caveat that the use of genital skin
flaps and grafts should be avoided due to very high long-
term failure rates.143, 219-221
Future Directions
Much of the literature on the topic urethral strictures
POST-OPERATIVE FOLLOW-UP consists of single surgeon or single institution case series
33. Clinicians should monitor urethral stricture with inconsistent definitions of stricture length, location,
patients to identify symptomatic recurrence and etiology; success of treatment; and follow up. These
following dilation, direct visual internal inconsistencies make comparisons between studies
urethrotomy, or urethroplasty. (Expert Opinion) difficult, while also providing ample opportunities for future
research. To improve the quality of research, the Panel
Urethral stricture recurrence following endoscopic
recommends the following:
treatment or urethroplasty can occur at any time in the
postoperative period, and, because of this, a specific  Standardize research terms to allow comparison
regimen for postoperative follow-up cannot be reliably between centers; specifically, the International
determined. The surgeon may consider more frequent Consultation on Urological Diseases nomenclature
follow-up intervals in men at an increased risk for stricture should be used. For example, the term "urethral
recurrence including those with prior failed treatment stricture" should be applied to a narrowing of the
(multiple endoscopic procedures or previous anterior urethra that restrict the flow of urine.
urethroplasty), tobacco use, diabetes, increasing stricture
22

 Utilization of an urethral stricture classification system  The efficacy of injection or balloon-coated anti-
that organizes the disease process, allows for proliferative or other pharmacological agents at time
improved patient counseling on expected outcomes, of endoscopic treatment for penile urethral stricture,
and better facilitates comparison of similar strictures previous failed urethroplasty, posterior urethral
across research studies.237, 238 Future urethroplasty stenosis, and bladder neck contracture.
research should include classification systems to  The relationship between of urethroplasty and ED.
better evaluate and compare uniform strictures.  Role of urethral transection in urethroplasty regarding
 In studies of the treatment of urethral strictures, morbidity and outcomes.
multiple criteria for success should be reported.  Dissemination and implementation of optimal
When data is available, studies should report success perioperative antibiotic strategies for urethrotomy and
based on several criteria: PRMs, symptoms, urethroplasty.239, 240
uroflowmetry, radiography, cystoscopy, and need for  Determination of the ideal tissue for substitution
subsequent procedures. This would facilitate urethroplasty.
comparison between multiple studies. A consensus  The optimal tissue and urethroplasty technique for
primary outcome measure should be considered for urethral stricture following phalloplasty.
future RCT and registry studies.
 The duration of follow-up based on time of last clinic
visit, telephone contact, or absence of known
treatment for recurrence should be reported in all Abbreviations
studies of urethral stricture treatment. Time-to-event
analysis (Kaplan-Meier curves) should be reported. AUA American Urological Association
 Multi-institutional collaboration should be formed to AUSAI American Urological Association
evaluate management of uncommon diagnoses such Symptom Index
as PFUI, hypospadias, panurethral strictures, and LS. CIC Clean intermittent catheterization
DVIU Direct visual internal urethrotomy
Urethral stricture remains a subject of active investigation.
ED Erectile dysfunction
The Panel suggests the following issues in future
IIEF International index of erectile function
investigations:
LS Lichen sclerosus
 Basic science and epidemiological research into the LUTS Lower urinary tract symptoms
etiology of urethral strictures. NGB Neurogenic bladder
 Continued evaluation of robotic techniques to treat PFUD Pelvic fracture urethral defects
posterior urethral strictures and those extending into PFUI Pelvic fracture urethral injury
the proximal bulbar urethra. PGC Practice Guidelines Committee
 Prevention of catheter associated urethral injury and PRM Patient reported measures
traumatic strictures through educational efforts on PVR Post-void residual
proper technique of catheter insertion and QoL Quality of life
management after insertion. RCT Randomized controlled trial
 Studies on the effectiveness of early diagnosis and RUG Retrograde urethrography
treatment of LS toward prevention of disease SP Suprapubic
progression and urethral stricture formation. UTI Urinary tract infection
 Basic science and animal studies using novel graft VCUG Voiding cystourethrography
materials for urethral reconstruction (i.e., stem cells, VUAS Vesicourethral anastomotic stenosis
tissue-engineered scaffolds).
 Long-term follow-up for adults in patients who have
been treated as children, such as urethral stricture in
adults after hypospadias repair.
 Further evaluation of alternative sources of
autologous graft material.
23

URETHRAL STRICTURE DISEASE PANEL, CONSULTANTS, AND STAFF

Panel 2016 Jonathan R, Treadwell, PhD
Hunter Wessells, MD, Co-Chair ECRI
University of Washington
Seattle, WA Staff 2016
Heddy Hubbard, PhD, MPH, RN, FAAN
Richard A. Santucci, MD, Co-Chair Abid Khan, MHS, MPP
The Detroit Medical Center Erin Kirkby, MS
Detroit, MI Shalini Selvarajah, MD
Nenellia K. Bronson, MA
Kenneth W. Angermeier, MD Leila Rahimi, MHS
Cleveland Clinic Brooke Bixler, MPH
Cleveland, OH
Amendment Panel 2023
Sean P. Elliott, MD Hunter Wessells, MD, Chair
University of Minnesota University of Washington
Minneapolis, MN Seattle, WA
Christopher M. Gonzales, MD Alex Vanni, MD

Northwestern Medical Faculty Foundation Lahey Clinic Medical Center
Chicago, IL Burlington, MA
Ron T. Kodama, MD Allen Morey, MD

Sunnybrook Heath Sciences Centre UT Southwestern Medical Center
Toronto, ON Canada Dallas, Texas
Andrew C. Peterson, MD Consultants 2023

Duke University Medical Center Lesley Souter, PhD
Durham, NC Nomadic EBM Methodology
Keith Rourke, MD Staff 2023

University of Alberta Erin Kirkby, MS
Edmonton, AB Canada Leila Rahimi, MPH
Brooke Bixler, MPH
John T. Stoffel, MD (PGC Representative) Sennett K. Kim
University of Michigan Medical Center Chelsi Matthews
Ann Arbor, MI
Alex Vanni, MD CONFLICT OF INTEREST DISCLOSURES

Lahey Clinic Medical Center
Burlington, MA
2016
Bryan Voelzke, MD All panel members completed COI disclosures.

University of Washington Disclosures listed include both topic– and non-topic-
Seattle, WA related relationships.
Lee Zhao, MD Consultant/Advisor: Sean Elliott: American Medical

NYU Medical Center Systems, GT Urological
New York, NY
Meeting Participant or Lecturer: Kenneth Angermeier:
American Medical Systems; Sean
Consultants 2016 Elliott: American Medical Systems; Ron Kodama: Journal
of Urology/GURS; Andrew Peterson: American Medical
24

Systems, Inc.; Hunter Wessells: National Institutes of John D. Denstedt, MD

Health Daniel David Dugi III, MD
Margit M. Fisch, MD
Scientific Study or Trial: Ron Kodama: Journal of Brian J. Flynn, MD
Urology/GURS; Andrew Peterson: American Medical Reynaldo G. Gomez, MD
Systems, Inc.; John Stoffel: Uroplasty; Hunter Wessells: Uri Gur, MD
National Institutes of Health Ty T. Higuchi, MD
James R. Jezior, MD
Leadership Position: Sean Elliott: Percuvision; Ron Melissa R. Kaufman, MD
Kodama: Journal of Urology, GURS; Andrew Peterson: Louis R. Kavoussi, MD
Society of Government Service Urologists Southeastern Sanjay B. Kulkarni, MD
Section, AUA Board of Directors, GURS Board of Deborah J. Lightner, MD
Directors Bahaa Sami Malaeb, MD
Joshua J. Meeks, MD, PhD
Other: Christopher Gonzalez: American Medical Douglas F. Milam, MD
Systems; Hunter Wessells: National Institutes of Health Manoj Monga, MD
Raul Caesar Ordorica, MD
CONFLICT OF INTEREST DISCLOSURES Craig A. Peters, MD
Robert Pickard, MD
2023 Kevin McVary, MD
Hassan Razvi, MD
All panel members completed COI disclosures. Daniel I. Rosenstein, MD
Disclosures listed include both topic– and non-topic- Charles L. Secrest, MD
related relationships. Eila Curlee Skinner, MD
Daniel Stein, MD
Meeting Participant or Lecturer: Allen Morey: Boston Chandru P. Sundaram, MD
Scientific, Coloplast Ryan P. Terlecki, MD
Jeremy Brian Tonkin, MD
Scientific Study or Trial: Alex Vanni: Boston Scientific, Ramon Virasoro, MD
Ellison Foundation Grant; Hunter Wessells: NIH J. Stuart Wolf, Jr., MD
Hadley M. Wood, MD
2016 PEER REVIEWERS Guo-bing Xiong, MD
We are grateful to the persons listed below who 2023 PEER REVIEWERS
contributed to the Guideline by providing comments
during the peer review process. Their reviews do not We are grateful to the persons listed below who
necessarily imply endorsement of the Guideline. contributed to the Guideline by providing comments
during the peer review process. Their reviews do not
Jennifer T. Anger, MD necessarily imply endorsement of the Guideline.
Noel A. Armenakas, MD
Mark S. Austenfeld, MD Kenneth W. Angermeier, MD
Gregory T. Bales, MD Erin Travis Bird, MD
Stephen A. Boorjian, MD, FACS
Guido Barbagli, MD Sam Chang, MD
John M. Barry, MD John D. Denstedt, MD, FRCSC
William W. Bohnert, MD Sean P. Elliott, MD
Timothy C. Brand, MD David A. Ginsberg, MD
Rodney H. Breau, MD Christopher M. Gonzalez, MD
Benjamin N. Breyer, MD Ron Kodama MD FRCSC
Joshua A. Broghammer, MD Gary Evan Lemack, MD
Jill C. Buckley, MD Edward M. Messing, MD, FACS
Frank N. Burks, MD Matthew Edward Nielsen, MD
Steven Eric Canfield, MD Andrew C. Peterson
Justin Chee, MD Phillip M. Pierorazio
Muhammad S. Choudhury, MD Hassan Razvi, MD
Peter E. Clark, MD Keith Rourke
25

Richard A. Santucci indications, contraindications, precautions and warnings.

Angela M. Smith, MD These guidelines and best practice statements are not in-
Thomas F. Stringer, MD tended to provide legal advice about use and misuse of
Bryan Voelzke, MD
these substances.
Lee Zhao, MD
Although guidelines are intended to encourage best
DISCLAIMER practices and potentially encompass available
technologies with sufficient data as of close of the
This document was written by the Urethral Stricture
literature review, they are necessarily time-limited.
Guideline Panel of the American Urological Association
Guidelines cannot include evaluation of all data on
Education and Research, Inc., which was created in 2015.
emerging technologies or management, including those
The Practice Guidelines Committee (PGC) of the AUA
that are FDA-approved, which may immediately come to
selected the Panel Chair. Panel members were selected
represent accepted clinical practices.
by the Chair. Membership of the panel included
specialists with specific expertise on this disorder. The For this reason, the AUA does not regard technologies or
mission of the panel was to develop recommendations management which are too new to be addressed by this
that are analysis-based or consensus-based, depending guideline as necessarily experimental or investigational.
on panel processes and available data, for optimal clinical
practices in the diagnosis and treatment of stress urinary
incontinence.
Funding of the panel was provided by the AUA. Panel

members received no remuneration for their work. Each
member of the panel provides an ongoing conflict of
interest disclosure to the AUA.
While these guidelines do not necessarily establish the

standard of care, AUA seeks to recommend and to
encourage compliance by practitioners with current best
practices related to the condition being treated. As
medical knowledge expands and technology advances,
the guidelines will change. Today these evidence-based
guidelines statements represent not absolute mandates
but provisional proposals for treatment under the specific
conditions described in each document. For all these
reasons, the guidelines do not pre-empt physician
judgment in individual cases.
Treating physicians must take into account variations in

resources, and patient tolerances, needs, and
preferences. Conformance with any clinical guideline
does not guarantee a successful outcome. The guideline
text may include information or recommendations about
certain drug uses (‘off label‘) that are not approved by the
Food and Drug Administration (FDA), or about
medications or substances not subject to the FDA
approval process. AUA urges strict compliance with all
government regulations and protocols for prescription and
use of these substances. The physician is encouraged to
carefully follow all available prescribing information about
26

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40

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