My (28M) urethral stricture story. Finally had my urethroplasty done after a failed DVIU.
Hello, fellows who suffer from this troublesome disease. I am a 28M that just had my urethroplasty with buccal mucosal graft done after one failed urethrotomy and many many years of suffering.
I believe the etiology of my urethral stricture was iatrogenic. In childhood (15 years old) I had a major abdominal blunt trauma (car accident) that left me with a perforated jejunum (that is the first part of the small intestine), which was solved with surgical treatment. Naturally, after the procedure I've had a Foley catheter for about 1 week and I remember clearly that extracting the catheter was a brutal and painful experience.
Since then I've slowly noticed that I had a diminished stream, straining when urinating, painful urination (dysuria), and sensation of incomplete voiding. These changes were so incremental that made me think "That's just who I am, maybe this is just a feature of my body".
Fast forward into medical school and during the urology class we've been taught about urethral strictures. I felt stricken by a lightning because all the symptoms matched, especially when they discussed the causes (gonorrhea - which I never had, and periprocedural Foley catheter microtrauma).
Naturally, I went to the doctor who presented this course and told him that I think I might have this very problem - urethral stricture. After further testing that you all know about - uroflowmetry (max flow rate - 9 ml/s) and a retrograde urethrography, the diagnostic was clear - bulbar urethral stricture measuring 3cm with a very narrow (Hank Hill pun intended) urethral lumen.
Discussing treatment options with my urologist and further reading of guidelines, the solution was a urethrotomy followed or not by a urethroplasty. One could argue that considering the success rate for each procedure (urethrotomy: 40-50% success versus urethroplasty: 85-95% success) I could've jumped directly with urethroplasty. But my doctor said that even if there's a small chance to heal with this relatively minimally invasive procedure, we should try urethrotomy first.
So, in 2019 I underwent a (cold knife optical) urethrotomy with the Sachse urethrotome. I was awake during the procedure (spinal anesthesia) and saw the bulbo-membranous stricture with multiple synechiae (adhesions). After sliding the knife through them just 3 times the lumen widened considerably and my doctor said that we shouldn't cut further because we must damage the tissue as little as possible in order to prevent fulminant scarring process. So we stopped and after 3 days the Foley catheter was removed.
Goddamn, the first piss was extraordinary, max flow was 28 ml/s, and after the inevitable residual bleeding and sensitivity of the area, in 2 weeks I was fully recovered, just before my residency exam where I chose gastroenterology as my specialty.
Unfortunately, the statistics of nearly 60% recurrence rate after urethrotomy did not spare me and after 2 years I've started to have the same symptoms again. The current guidelines advise against undergoing a second urethrotomy (DVIU) because the stricture will come back much quicker, you end up kicking the can down the road. I sought to have the other procedure done – BMG urethroplasty.
Now, urethroplasty with ventral buccal mucosal graft is a difficult surgery with a steep learning curve, so make sure you find a urologist who is highly specialized in this procedure. It is also much more invasive than a simple urethrotomy because you will go under general anesthesia, they will open up your perineum in bulbar strictures (or even the need to pull the penis through the perineum in case of penile urethral strictures), it typically lasts about 3 hours and they need to harvest a segment of your inner cheek (buccal mucosal graft).
I was referred by my doctor to one of his colleagues who is specialized in urethroplasties - his PhD thesis was done by analyzing the procedures he's done in 1 year. The results were pretty encouraging: Out of 80 patients with ventral BMG urethroplasty, 70 were a success after 1 year.
I underwent the procedure nearly 2 weeks ago, and was discharged from the hospital after 5 days with a special Foley catheter in place. The first week is the worst as you'll need painkillers and family to take care of your weakened state, but it gets better. I need to stay 15 days with the catheter in and the doctor will take it off in 3 days, after making sure that there are no "leakages" following another urethrography. In this time, make sure to properly clean the area twice a day with Betadine and Tetracycline gel. Nigh-time erections may wake you up, you just have to wait them out.
I really can't wait to pee like a normal person again, something that many people take for granted. I'm more optimistic about this second procedure as it has a much larger percentage of success and may even prove as a definitive cure. Since this surgical treatment has been around since 1993, there are not many studies that show efficacy at 10 or 15 years. Only one meta-analysis shows that it gradually decreases over time, but still above 80% at a 10-year mark and above 70% at a 15-year mark. Another good part is, unlike the gloomy statistics about a redo urethrotomy DVIU that is bound to fail, a redo urethroplasty renders the same spectacular over 90% success rate.
Please, don't delay treatment as many patients waiting for urethrotomy or urethroplasty may have complications such as intravesical stones, a higher risk of urinary tract infections and, the most dreadful of all, vesical diverticula. Let me explain the last one:
The detrusor muscle of the bladder is "fighting" to push the urine through that narrow opening of your urethra and that makes the inner layers (mucosa) of your urinary vesica to herniate through the muscle fibers of the detrusor, causing vesical diverticula. There are very dangerous as they can be very prone to infections and abscesses.
Keep in mind that I haven't even mentioned the impact on quality of life of urethral strictures - while all our peers void in under 20 seconds, we strain near the toilet for a solid 2 minutes!
Seek treatment! It will hurt as hell in the first days post-surgery, but:
- Your quality of life will improve. Dramatically.
- You get rid of those potential complications - UTI, stones, vesical diverticula.
- There is not a risk for erectile function (because we're not talking here about radical prostatectomy, for example, where almost always the surgeon cuts through the nervous bands emerging from the sacral plexus responsible for erection).
- You get to pee, at least if you fall into the success side of statistics, like a normal person again.
Good luck and feel free to ask specific questions.