Urethral stricture: Two factors drive complication risk

San Diego-Urethral stricture is a morbid disorder for many patients, and old age and greater stricture length are associated with a particularly high risk of complications, Canadian researchers report.

Results of a retrospective study based on a large, single-practice cohort demonstrate a higher rate than typically expected of complications among men with anterior urethral stricture, reported co-author Keith Rourke, MD, at the AUA annual meeting in San Diego.

Dr. Rourke analyzed presenting features, complications, and potential risk factors for complications in a series of 611 patients who presented with anterior urethral stricture over a period of 6 years. The patients had a mean age of 49 years, their strictures most often involved the bulbar urethra (69%), and were most often idiopathic (47%).

Overall, 240 patients (39%) were identified as having one or more complications directly related to urethral stricture. Acute urinary retention was most common (30%), followed by difficult catheterization (14%), urethral abscess (7%), and renal failure (4%).

Potential risk factors investigated included patient age along with stricture length, etiology, location, and presenting symptoms. With patients divided into two groups according to whether they were younger or older than the cohort’s mean age, patients older than 50 years had a significantly higher rate of complications than their younger counterparts (44% vs. 36%).

Stricture length was also significantly associated with increased risk of complications, as the rate of complications was 50% among men whose stricture was 6 cm in length or longer versus 36% for those with shorter strictures.

“It is well recognized that urethral stricture can cause lower urinary tract symptoms affecting quality of life, and when patients develop stricture recurrence after initial endoscopic treatment, the decision to perform urethroplasty is predominantly based on providing symptomatic relief. While it has also been appreciated that urethral stricture can lead to some significant complications, the degree to which these problems exist has not been well described,” said Dr. Rourke, associate professor, department of surgery, division of urology, University of Alberta, Edmonton, AB.

“Our study indicates that urethral stricture is a morbid condition for many patients, and we believe this information should also be taken into account when counseling patients about management. Even though the rate of urethroplasty success may be potentially lower among men who are older and those with longer strictures, we believe these at-risk individuals would be best served by reconstruction and should be strongly encouraged to undergo definitive surgical treatment.”

Risk factors not surprising

Dr. Rourke noted that the identification of stricture length as a risk factor for stricture-related complications makes intuitive sense, since a longer stricture may cause higher grade obstruction than a shorter stricture and may also be associated with more inflammation. The association between older age and complication risk was also not surprising, as older patients likely had a longer standing obstruction that would increase their likelihood of developing a complication.

Complication rates also varied by stricture location, with penile strictures being associated with the highest rate (48%) followed by panurethral strictures (41%) and bulbar strictures (36%), and the difference comparing penile and bulbar strictures was statistically significant. However, Dr. Rourke noted that there might be some confounding of these data by the fact that penile strictures tend to be longer than those involving other locations.

Dr. Rourke acknowledged that the complication rate in his cohort might be an overestimate considering that as a reconstructive urologist, he may be seeing worst-case scenario patients referred after failing endoscopic treatment. However, as an offsetting factor, his practice also includes a large general urology population, and many patients included in the study were referred by their primary care physician because of voiding symptoms or other problems without having an established stricture diagnosis.UT