What is a Urethral Stricture?
A urethral stricture is a scar of the urethra (the urine tube that you “pee” through) that causes narrowing and blockage of urinary flow from your bladder. This blockage leads to difficulties urinating (>90% of patients), pain (~70% of patients), urinary infections (~20% of patients), blood in the urine (hematuria – 20%), sudden urinary blockage (up to 30%), kidney blockage (5%) and sometimes abscesses around the urethra (2-3%). Most patients have attempts to open up the blockage using scope procedures that typically do not cure the blockage long-term and only temporarily help the problem(s).
What is Urethroplasty?
Urethroplasty (sometimes called urethral reconstruction) is a surgery using an incision to repair the scar tissue that causes the urethral blockage. Often the success rate is over 90%.
The goal of urethral reconstruction is to widen the urethra to improve urine flow. There are different ways your surgeon can do this:
- The diseased part of the urethra (the scar tissue) can be cut out. Then the two healthy ends can be reattached.
- Sometimes, the healthy ends cannot be reattached. In these cases, tissue from other parts of the body may be added to the urethra to widen it.
- In other instances, two operations may be needed. During the first operation (called 1st stage urethroplasty), a tissue is taken from the mouth and placed on the underside of the penis. In the second operation (2nd stage urethroplasty), the new and healthy tissue is folded back to create a new urethra.
The type of urethral reconstruction you have is based on many factors. You and your surgeon will discuss which of these options is best for you.
Why does scar tissue form in the urine channel (urethra)?
There are many causes of urethral stricture including prior urethral injury, prior procedures such as catheter placement, prior surgery (such as prostate surgery), certain infections, radiation treatment, hypospadias, or a skin condition called lichen sclerosus which can affect the penis both inside and out.
Will urethroplasty cause sexual issues?
In general, it is not likely to have trouble with sex after this surgery. Some patients may have temporary issues in the early period after surgery but this is seldom permanent (< 2%). Some patients may already have trouble with erections in addition to the urethral stricture. Your urologist can treat both of these problems.
Preparing for Your Surgery
To help you prepare for surgery, you will need the following appointments:
Appointment with the Preoperative Center
At the Preoperative Center, you will have routine tests that you will need for your surgery (like blood tests, X-rays and EKGs). You will also meet with a nurse who will review specific instructions that you should follow before your surgery. For example, she will tell you which medicines and foods you may need to avoid before surgery.
Appointments with an Advanced Practitioner
You will meet with an advanced practitioner (a physician assistant or nurse practitioner). He or she will give you a physical exam and will talk with you about preparing for and recovering from your surgery. The practitioner will address any questions or concerns you have at this visit. Please read this entire guide before your visit with the advanced practitioner.
The Day of Your Surgery
When you arrive at the Hospital Admissions Department.
After registering, you will go to Ambulatory Surgery and then change into a hospital gown.
Then you will be brought to the “pre-op hold and prep” area.
- Here you will have your vital signs (like your heart rate and blood pressure) checked and have a chance to speak with your surgeon. You will also meet the anesthesiologist. He or she will place an intravenous line (IV) in your arm and will give you medicine through the line to make you sleepy.
- You will be in the pre-op hold and prep area for about 1–2 hours. You may want to bring something to read or listen to.
Next, you will be taken to the operating room.
- Here, the anesthesiologist will attach you to various monitors. He or she will also give you oxygen through a small mask placed over your nose and mouth. Soon after this, you will drift off to sleep.
When the surgery is over, you will be taken to the recovery room.
- When you arrive in the recovery room (also known as the Post-Anesthesia Care Unit or PACU), you will be very sleepy but able to hear those around you.
- You can expect to be in the PACU for about 2 hours. You will leave the PACU once you appear to be recovering well and in most cases are discharged home on the same day.
Recovery at Home:
Here is what you can expect after your surgery:
You will have an incision (wound) most commonly between your scrotum and anus.
Some patients may have an incision on the penis (your surgeon will discuss this with you before surgery).
- The incision will be about 3–4 inches. You might feel some pain at your incision, which is normal.
- Your incision will be closed with stitches. These will dissolve (melt away) and do not need to be removed.
- You may have tissue taken from the inside of your mouth (buccal graft) to reconstruct your urethra.
You will have a urethral catheter (also known as a “Foley catheter”).
- This catheter is a small tube that drains urine from your bladder (through your urethra). It is held firmly in place by a small balloon that is inflated with water. You will not need to urinate while this tube is in place.
- You will need to clean the end of your penis where the catheter enters your body to prevent infection. Your nurse will show you how.
- You may have these normal symptoms:
- Urge to urinate even though your bladder is empty (this feeling will gradually decrease)
- Blood in the urine after surgery will occur occasionally while the catheter is in place.
- Urine that leaks once in a while around the outside of the catheter (this will most likely happen when you move your bowels)
In addition to the urethral catheter, you may have another tube (called a subrapubic tube) to drain urine (through a small opening in your abdomen).
You can expect these symptoms.
They are normal and should go away with time.
- Bruising and mild bleeding at your incision
- Mild bruising and swelling of your scrotum.
- Mild pain in perineum (the area between your anus and scrotum), scrotum and hips. This should improve with activity during the first week after surgery.
- Urine or bloody fluid leaking from the end of the penis or around the catheter. When this happens, you may feel pain and pressure.
- Bladder spasms. These can feel like pressure or pain and cause urine to leak around the catheter
- Erections while you sleep. This is normal and impossible to prevent, and will not hurt the repair
- Mild swelling and discomfort in your cheeks, if tissue was taken from your mouth to reconstruct your urethra.
You will receive pain medicines and other medicines.
Most people have some pain for the first 3-4 weeks after surgery, but the pain is usually not very bad. Ibuprofen and/or Tylenol can be taken every 6 hours for pain. If a buccal mucosa graft has been harvested, a mouth wash will be prescribed to help with the discomfort.
You will slowly introduce foods to your diet.
- Most patients start eating again the day of surgery. You will start with liquids or soft foods (like toast). As soon as you can eat solid food, you can choose your meals.
You will recover quicker by doing certain activities.
- To help improve your circulation (blood flow), wiggle your toes and ankles every once in a while. Do not cross your legs.
- To help prevent lung problems, take deep breaths and cough.
- Change positions in bed (from side to side) every few hours. This will help prevent muscle aches and other issues related to surgery.
You may start walking the day of your surgery.
- Walking is very important since it helps to prevent blood clots (clumps that form when your blood thickens) in your legs. Even a short walk will help a lot.
Recovery at Home: Home Care Instructions
Here are some tips for caring for yourself at home. We will give you more detailed instructions before you leave the hospital.
Try to get some activity each day. Walking is a good choice.
Do not drive if talking prescription pain medicine
Morning erections are expected and will not affect your healing. You will still ejaculate, but it may not be as forceful. Urethral reconstruction will not affect your fertility.
While the catheter is in place (usually 3 weeks), you will need to try to avoid the following:
- Lifting more than 20 pounds
- Vigorous activity, such as yardwork or heavy housework
If you have a perineal incision (between the scrotum and anus), try to avoid putting pressure on this area for 6 months. Recline while you are sitting and you may use an air-filled donut or soft cushion to make you more comfortable. Avoid any activities that involve straddling (such as bike or horseback riding).
Sexual activity may resume once the catheter is removed. It is normal to have some slight discomfort with erections in the first month after surgery, but this always goes away.
- Regular exercise and activity may resume once your catheter is removed.
- Take your usual medicines as prescribed, unless you were told otherwise.
- You will be prescribed an antibiotic for your postoperative x-ray, and medication to control bladder spasms. Take these as prescribed.
Eating and drinking
- Drink a lot of water every day. Restart your usual diet when you feel ready.
Anesthesia and pain medicine can affect your bowel movements. It will take time for your bowel movements to be normal. To prevent constipation:
- Drink apple juice, prune juice and plenty of water.
- Eat high-fiber foods (whole grains, leafy greens, and other vegetables and fruits).
- Try a fiber supplement (for example, Metamucil or Citrucel) and a stool softener (for example, Colace).
Bathing/Caring for Your Incision
You can shower 48 hours after surgery. If you had a first stage urethroplasty, wait until the dressing is removed to shower.
If you had a first stage urethroplasty, you may need to cover your graft with aquafor or other non-adherent dressing daily until the 2nd stage surgical closure.
- If you had tissue taken from your mouth for a graft, you will need to clean the inside of your mouth with mouthwash or a special solution, and will have a mouthwash for pain control if needed.
Returning to work
- When you return to work will depend on your recovery and the type of job you have. On average, most patients need 3-4 weeks to recover. Your surgeon will let you know when you can go back to work.
Call your surgeon if you have any of the following:
- Your catheter becomes blocked or falls out
- Your incision becomes red or swollen, opens or drains pus
- The skin around your incision becomes warmer than elsewhere
- Decreased or no urine from the catheter for 2 hours
- Temperature greater than 101F (38C)
- Nausea or vomiting
- Severe pain not controlled by pain medications
- Continuous or painful bladder spasms that do not go away
- Every day things usually get a little easier.
- Do not be afraid to take pain medicine when you are uncomfortable.
- Walk, walk and walk some more. It will help speed your recovery.
- Ask us about anything that concerns you.
Recovery at Home: Common Questions About Catheters
Before you leave the hospital, we will explain how to care for your catheter. Here are some common questions patients have about catheters.
My catheter is leaking! Is this normal?
This may happen if you are having a bladder spasm or bowel movement. Take your bladder spasm medications and avoid constipation if possible. If urine does not drain from the catheter, you need to call your surgeon.
There is blood in my leg bag! What should I do?
Your urine may be pink or dark brownish-red after surgery. Make sure to drink a lot to help clear this up. Please call your surgeon if your urine is bright red and does not become clear in 4 hours after you have increased the amount you drink.
How long will my catheter be in?
You will have a catheter for 1-4 weeks after surgery. It will most likely be removed at your first follow-up appointment.
Will my catheter fall out?
No, the catheter will not fall out. After the catheter was inserted, a balloon at the tip was inflated with water. This inflated balloon keeps the catheter in place. Before the catheter is removed, the balloon is deflated and the catheter slides out easily. In the rare case that the catheter falls out or becomes blocked, call your surgeon right away.
Can I take a bath with the catheter in?
No, you cannot soak in water (in a tub, hot tub, pool or Jacuzzi) while you have a catheter. You may take a shower.
Does it matter what type of clothes I wear?
No, you can wear whatever makes you comfortable. You may find wearing a jogging suit or sweat pants more comfortable than other pants. You can wear either boxer shorts or briefs.
Your Follow-Up Visit
Your first follow-up visit will be 1-4 weeks after you leave the hospital. We will schedule this visit for you. If you do not receive a letter in 1 week that confirms your appointment, call your surgeon’s office. Here is what you can expect at your follow-up visit:
- You will have a special type of X-ray of the bladder and urethra (called a voiding cystourethrogram). This will show whether the urethra has healed enough for the catheter to be removed. Depending on the results, the catheter may need to stay in longer.
The day your catheter is removed, you may feel burning or see a bit of blood when you pass urine. Drinking fluid will dilute (or “water down”) the urine and help relieve these symptoms.
Take your antibiotic 1 hour prior to X-ray and again later that evening.
Do not take medication for bladder spasms (such as oxybutynin, Ditropan) for 24 hours before your follow-up visit (when the voiding cystourethrogram is performed)
- After your first follow-up visit, you will be seen in 4-6 months, 12 months, and yearly thereafter. Always come to your appointments with a full bladder. (You will need a full bladder for a special test that will be used to check your progress after surgery.)