An excellent option for treatment of discreet, short strictures of the urethral meatus, which is the opening of the urethra at the tip of the penis, is a meatotomy. A meatotomy is incision of the urethral opening with subsequent placement of sutures at the edges. When patients are found to have narrowing at the very tip of the penis, confirmed with Bougie calibration, we then perform a RUG to determine the extent of the disease. The following is a RUG of a patient with stricture disease limited to the meatus itself.
RUG of meatal stenosis
It is important to know the extent of the stricture before performing a meatotomy, as this is not necessarily a good option for longer strictures if the goal is to have the urethral opening within the glans penis and not the undersurface of the penis. A meatotomy is a simple outpatient procedure.
In cases of Lichen Sclerosis with urethral stricture that extend into the fossa navicularis, a reasonable option is an extended meatotomy. Although the opening of the urethra is then elongated and extends slightly towards the undersurface of the penis, this effectively relieves the obstruction; a more complex open reconstruction does not necessarily yield an improved cosmetic or functional result.
When patients have extensive recurrent strictures of the distal urethra and desire a simple procedure to relieve the obstruction, a perineal urethrostomy is an option.
A perineal urethrostomy is an opening under the scrotum connecting the skin to the urethra. During urination, the urine exits from the urethrostomy and therefore does not have to travel through the narrow distal stricture. This is particularly appealing to older patients with multiple medical problems who desire relatively simple definitive treatment.
Most patients do not choose this option, as they do not want to sit to urinate or have semen exit from under the scrotum during ejaculation. This procedure, especially if not performed properly, can be complicated by narrowing at the opening, and stenosis of the urethrostomy can be challenging to repair.
It is important to carefully evaluate the urethra with a RUG and VCUG because strictures that extend into the proximal bulbar urethra (near the membranous urethra) are not well suited to urethrostomy as the skin flap cannot easily be advanced deep into the pelvis where the urethra is normal. In rare cases, we have used a buccal mucosa graft to augment the proximal urethra just so the skin would then reach the urethra without tension.