Epidemiology and Diagnosis

Urethral stricture disease rarely presents for the first time acutely outside of the trauma setting; however, there is always a group of patients who present late with retention of urine consequent to an undiagnosed stricture. Most patients with urethral strictures describe a typical progressive deterioration in urine flow rate and loss of flow caliber, eventually describing storage, voiding, and postmicturition LUTS. Some have recurrent UTI and a proportion will describe bleeding per urethra that is not always associated with voiding. If symptoms progress without intervention, patients may in time present with AUR. Some patients with meatal stenosis and/or phimosis may also present in AUR, although the majority of these patients will also usually have had deteriorating voiding symptoms for some time.

Traumatic disruption of the male urethra, causing failure of bladder drainage, is a well-described feature of many types of injuries; most commonly pelvic fractures, fall-astride injuries, foreign bodies, etc.; these are coveredin Sect. 11.2.5.5.

In patients presenting acutely with UR who are known to have urethral stricture, the diagnosis is simple. If it is the first presentation, then a comprehensive history of deteriorating LUTS can raise the suspicion of stricture disease. This is especially true in patients younger than 40, or those with a history of urinary tract instrumentation, injuries, or foreign bodies. The examination may be unremarkable, but in some cases, as previously, a bladder will be palpable above the symphysis pubis. DRE should be normal; however, some patients may have coexisting BPE. In some cases, an area of thickening of the corpus spongiosum is palpable in the penile urethra or in the bulbar urethra, felt at the perineum; this suggests severe stricturing that will almost certainly necessitate surgical intervention (Weiss et al. 2001). There may be features of UTI, including epididymitis, and these would be corroborated by a history of dysuria and cloudy, offensive urine.

Definitive diagnosis is sometimes not made until attempts at urethral catheterization are made, which will invariably fail in patients with AUR secondary to stricture^). Alternatively, if stricture is suspected, retrograde urethrography can be performed to identify the site and extent of the stricture(s). This also helps to guide future management.

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