MALE URETHRA: ANTERIOR AND POSTERIOR SECTIONS

The male urinary canal (urethra) is anatomically divided into two main sections:

Anterior Urethra This is the segment located within the penis. Sections:

• Meatal urethra (external opening)

• Fossa navicularis

• Penile urethra

• Bulbar urethra Most urethral strictures occur in this region.

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WHAT IS ANTERIOR URETHRAL STRICTURE?

Anterior urethral stricture is the narrowing of the inner diameter of the urethra (urinary channel). This narrowing makes urination difficult and, over time, may lead to:

• Difficulty urinating

• Thin urine stream

• Split urine stream

• Dribbling after urination

• Recurrent infections

• Incomplete bladder emptying

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WHAT CAUSES ANTERIOR URETHRAL STRICTURE?

Trauma

• Catheter insertion

• Endoscopic procedures

• Catheter-related injury

Infection

• Urethritis (especially previous infections)

Lichen Sclerosus

• A common cause of penile urethral and meatal strictures

Iatrogenic (Medical Intervention–Related)

• TUR surgeries

• Cystoscopy

• Radiotherapy

Idiopathic

• In some cases, no clear cause can be identified.

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ENDOSCOPIC TREATMENT OF ANTERIOR URETHRAL STRICTURE

Internal Urethrotomy (Endoscopic Incision)

This is the most commonly performed minimally invasive procedure.

How Is It Performed?

• The stricture is reached using an endoscope

• The narrowed area is incised internally to widen it

• The procedure is usually performed under spinal or general anesthesia

• A catheter is placed for a short period afterward

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Success Rate

After the first procedure:

• Success rate: 30–60%

Higher success is seen when:

• The stricture is short (<1–2 cm)

• It is a first-time stricture

• It is located in the bulbar urethra

In Recurrent Strictures

Repeating the same procedure:

• Significantly reduces success

After a second intervention:

• Long-term success: 0–40%

For this reason, clinical guidelines recommend open surgery (urethroplasty) for recurrent strictures.

 

DRUG-COATED BALLOON DILATION

This is a newer treatment method. Unlike standard dilation, the stricture is widened while simultaneously delivering a medication that suppresses scar formation.

Goal: Reduce the risk of recurrence.

How Is It Performed?

• The stricture is reached endoscopically

• A balloon is inflated at the narrowed segment

• The drug on the balloon (usually with anti-fibrotic properties) contacts the tissue

• Mechanical dilation and medication work together

Success Rate

According to guideline data:

• 1-year success rate: approximately 60%

It is promising in recurrent short bulbar strictures; however, long-term outcomes are still under evaluation.

Important Note:
Drug-coated balloon dilation is not covered by public insurance reimbursement in Turkey.

 

WHAT IS OPEN SURGERY (URETHROPLASTY) FOR ANTERIOR URETHRAL STRICTURE?

Open surgical treatment of anterior urethral stricture is called urethroplasty.

In recurrent, long, or endoscopy-resistant strictures, open surgery is the most effective and permanent treatment method.

When the success rate of closed (endoscopic) techniques decreases, open repair is recommended for a lasting solution.

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1) END-TO-END URETHROPLASTY (ANASTOMOTIC URETHROPLASTY)

Indications

• Short segment (<2 cm) bulbar urethral strictures

• Strictures following perineal trauma

• Single, dense fibrotic strictures

How Is It Performed?

• The strictured segment is completely removed

• The healthy ends are mobilized

• The ends are sutured together without tension

Goal: Completely remove the diseased segment.

Long-Term Success Rate: 85–95%

Advantages

• One of the most durable methods

• High success in a single session

• Low recurrence rate

Disadvantages

• May shorten the urethra

• Rare minimal change in penile length

• Risk of erectile dysfunction (usually temporary)

• Rare ejaculatory changes

Note: Especially ideal in traumatic strictures.

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2) GRAFT URETHROPLASTY (Patch Repair)

Preferred In:

• Strictures longer than 2 cm

• Penile urethral strictures

• Lichen sclerosus–associated strictures

• Segments too long for end-to-end repair

 

What Is a Graft?

A graft is healthy tissue taken from another part of the body.

The most commonly used graft in urethral reconstruction is buccal mucosa (inner cheek lining).

Why Buccal Mucosa?

• Easily accessible

• Durable and elastic

• Resistant to urine exposure

• Resistant to infection

• Excellent blood supply

For these reasons, it is the most commonly preferred graft worldwide.

Long-Term Success Rate: 80–90%

Success depends on:

• Location of the stricture

• Length

• Previous surgeries

Postoperative Course

• Hospital stay: Usually 1–3 days

• Catheter duration: Approximately 3–4 weeks

Possible Risks

1. Recurrence

   • Seen in 10–20% (graft repairs)

2. Urinary Incontinence

   • Very rare in anterior urethral surgery (<5%)

3. Erectile Dysfunction

   • Usually temporary

   • More common in traumatic cases

   • Permanent risk is low (around 1–5%)

Follow-Up

• 3-month check

• 6-month check

• 12-month check

• Uroflowmetry (urine flow measurement)

• Cystoscopy if suspected

Decreased urine flow in early follow-up may indicate recurrence.

 

URETHRAL STRICTURE DUE TO PELVIC FRACTURE

(Trauma-Related Posterior Urethral Injury)

Urethral stricture after pelvic fracture usually occurs following severe traffic accidents or high-energy trauma. This condition causes rupture or damage to the urethral segment between the prostate and bladder. Over time, scar tissue develops in this area, leading to partial or complete obstruction of the urinary channel.

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INITIAL EMERGENCY APPROACH AFTER PELVIC FRACTURE

At the time of trauma, the primary goals are:

• Protect the patient’s life

• Ensure safe bladder drainage

According to EAU guidelines, blind catheterization should not be performed after trauma, as it may worsen the injury.

Correct Emergency Approach

If the following are present:

• Blood in urine

• Inability to urinate

• Blood at the tip of the penis

Imaging is performed first (retrograde urethrography).

If urethral injury is confirmed:

• A catheter is placed into the bladder through the lower abdomen
  (Suprapubic catheter / cystostomy)

This method:

• Ensures safe urine drainage

• Protects the urethra

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WHAT HAPPENS IN THE LATE PERIOD?

After the initial healing process, scar tissue forms between the urethral ends, leading to posterior urethral stricture.

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DEFINITIVE TREATMENT: OPEN REPAIR (POSTERIOR URETHROPLASTY)

The gold standard treatment is open surgery.

How Is the Surgery Performed?

The operation is usually performed through the perineal area.

Steps:

1. Scar tissue is completely removed

2. Healthy urethral ends are identified

3. The ends are reconnected without tension

This restores urethral continuity.

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KEY TECHNICAL PRINCIPLES

For successful repair:

• Complete excision of scar tissue

• Tension-free anastomosis

• Preservation of prostate–bladder alignment

are critically important.

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POSTOPERATIVE COURSE

• Hospital stay: Usually 2–3 days

• Catheter duration: Approximately 3 weeks

Long-Term Success Rate: 85–90%

 

POSSIBLE RISKS

1. Urinary Incontinence

   • Generally low risk

   • On average below 5%

2. Erectile Dysfunction

   • Trauma itself already carries a risk

   • New onset after surgery: 5–15%

   • Often temporary

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FOLLOW-UP

According to EAU recommendations:

• 3-month check

• 6-month check

• 12-month check

Monitoring includes:

• Uroflowmetry (urine flow measurement)

• Symptom assessment

• Imaging if necessary

A decrease in urine flow may be an early sign of recurrence.