Urethrotomy and urethral dilation

This card covers urethrotomy and urethral dilation, two endoscopic procedures used to open a urethral stricture, which is a narrowing of the urine passage. It describes what the procedures involve, what recovery generally looks like and what sources say about recurrence. It is general information, and a person's own urologist decides which option suits their stricture.

What it is

The urethra is the tube that carries urine out of the body. A stricture is a band of scar tissue that narrows it and can block the flow of urine. The Cleveland Clinic lists infection, inflammation and trauma among causes, and notes that some strictures have no obvious cause. Terms used here are explained in the glossary.

The British Association of Urological Surgeons (BAUS) patient leaflet names two main endoscopic techniques. In dilation, the urethra is stretched with dilators of increasing size, which can be plastic or metal rods, or with a balloon. In optical urethrotomy, the stricture is cut from the inside with a small knife passed through a scope. BAUS notes that no cuts are made in the skin.

Why it is done

The aim is to relieve symptoms of blockage so that urine passes more easily. BAUS says these procedures are often used as an initial treatment because they are less invasive than reconstructive surgery, and that they are well-established and available at every urological unit in the UK. The NHS England commissioning policy on urethroplasty says urethrotomy and/or urethral dilation should be considered as first-line treatment for strictures shorter than 3 cm, unless the patient has a contraindication or, after counseling, prefers urethroplasty (open reconstruction of the urethra).

The same policy lists situations where reconstruction is considered instead: strictures longer than 3 cm, some long strictures linked with lichen sclerosus, and short bulbar strictures that have come back after at least one urethrotomy.

How it is done, in outline

BAUS says these procedures are usually done as day cases. For dilation, the urethra is lubricated with local anesthetic gel and stretched with dilators under local or general anesthesia, and the surgeon may also inspect the urethra with a telescope. For optical urethrotomy, an antibiotic is given into a vein, and the stricture is then cut internally, so there are no external stitches.

Afterward, a bladder catheter is often placed to hold the passage open while it heals. Most people having urethrotomy go home with the catheter in, according to BAUS, and some are taught to remove it themselves. Some people are also taught to dilate the urethra themselves with a catheter. For catheter care in general, see urinary catheters after surgery. The scope used is the kind of instrument described on the cystoscopy card.

Recovery

BAUS says a temporary catheter may be needed for one to ten days after the procedure, and that a catheter placed after dilation is normally removed in an outpatient clinic in that window. The Cleveland Clinic says most people feel better within a few days, and advises waiting for clearance before intense activity. It says burning on urination usually improves after several days.

The NHS England policy describes self-dilation, in which a person passes a catheter at intervals, as an alternative when urethroplasty is not wanted, for at least six months after urethrotomy. More recovery guidance is gathered in the recovery and rehabilitation hub.

Risks

Recurrence is the main limitation. BAUS states that endoscopic procedures rarely result in permanent cure, and it puts the chance of a stricture coming back and needing repeat or alternative treatment at between 1 in 2 and 1 in 10. The Cleveland Clinic gives a success rate of up to 60 percent for strictures shorter than 2 centimeters, falling over time, and says a stricture that returns after one dilation will usually keep returning, which is why more extensive surgery is generally discussed at that point. The NHS England policy quotes older studies in which 64 percent of men in a urethrotomy group needed further surgery or dilation, compared with 24 percent after urethroplasty.

BAUS lists other after-effects with approximate frequencies. Mild burning or bleeding when passing urine, and a urinary tract infection needing antibiotics, each occur in between 1 in 2 and 1 in 10 patients. A "false passage" (damage to the urethra needing further surgery or a suprapubic catheter) and an abscess around the urethra each occur in between 1 in 10 and 1 in 50. Delayed bleeding, reduced erection quality, penile bending and anesthetic or cardiovascular problems are each put at between 1 in 50 and 1 in 250.

The Cleveland Clinic advises calling a healthcare provider right away for an inability to pass urine, a clogged catheter that is not draining, signs of infection such as fever, chills or new pain on urinating, increased pain, or swelling.

Questions to ask your clinician

• How long and where is my stricture, and does that make urethrotomy or dilation a reasonable first choice?
• What are the chances that the stricture comes back, and how would we know?
• Will I need a catheter afterward, for how long, and who will remove it?
• Would I be taught to dilate myself, and for how long might that continue?
• Which symptoms should make me contact the team or seek urgent care?