The most common location for urethral strictures is the bulbar urethra. This portion of the urethra, also called the bulbous urethra, is under the scrotum, an area called the perineum. Unfortunately, the bulbar urethra is not well protected, unlike other structures such as the lungs that are protected by ribs and the brain, which is protected by the skull. The bulbar urethra is particularly susceptible to straddle trauma during sports, or from straddling the bar of a bicycle, or other straddle trauma such as being kicked. As this area is impacted, the bulbar urethra is crushed against bone. In some cases, there is immediate swelling and blood at the urethral opening at the tip of the penis. However, in many cases, the stricture subsequently develops slowly over time as the injury heals with a scar that slowly contracts. Some patients may not even remember a specific injury. Bulbar strictures secondary to straddle trauma are typically short.
The following are examples of bulbar stricture seen on a RUG:
When bulbar strictures are less than 1.5-2 cm in length, reasonable treatment options are direct vision internal urethrotomy and open urethral reconstruction. When the stricture length exceeds 1.5-2 cm, internal urethrotomy is always an option, but the success rate is very low and the best initial treatment option is open urethral reconstruction, also called urethroplasty The preferred technique for short strictures is excision and primary anastomosis. This is a procedure where the narrow segment is excised and the healthy ends are re-connected with sutures as shown. There is some elasticity or “give” when the urethra is mobilized, and there are several maneuvers that facilitate a tension free connection. Our technical success with this technique is greater than 98% (including re-do repairs). The following are several before and after films of patients who underwent reconstruction with excision and primary anastomosis at the Center for Reconstructive Urology
Before and After Imaging
However, when the stricture is longer, as shown in the following example, excisional repair is not a good choice because too much urethra would need to be removed, and the gap would be too great for the ends to be re-connected without tension. These are films of bulbar urethral strictures longer than 4 cm in length that are not amenable to excisional repair.
Long Bulbar Strictures
In these cases, our preferred approach is to incise the urethra and add buccal mucosa (a graft taken from the inside of the cheek) to augment and widen the narrow area of the urethra. Overall, bulbar strictures can be repaired with a very high success rate and a low complication rate.