Recurrent Bulbar Stricture After Traumatic Catheterisation in a Man with a Suprapubic Catheter

Assessment:

• Anatomy: Retrograde urethrogram and voiding cystourethrogram define length, calibre, location and whether the stricture is bulbar or extends into the membranous urethra. A 2.5 cm bulbar stricture is short and bulbar, which is favourable for reconstruction.
• Aetiology and history: Traumatic catheterisation suggests a focal ischaemic or mucosal injury rather than lichen sclerosus or a long inflammatory segment. Four prior urethrotomies, including two within the last year, are the key prognostic factor: recurrence after repeated urethrotomy is high, and further endoscopic treatment is very unlikely to be curative.
• Bladder function: With a suprapubic catheter and a chronically empty bladder, I need to know whether the bladder is trabeculated, whether there is detrusor underactivity, and whether the patient can void after reconstruction; urodynamics may be needed if there is doubt.
• Infection: Treat the mixed growth with a course of appropriate antibiotics before surgery, and consider whether the suprapubic tract is colonised.
• Comorbidity: Obesity (BMI 38) and diabetes increase wound and anaesthetic risk and favour a well-planned, single definitive procedure over repeated minor ones.

Decision: Recurrent strictures after multiple urethrotomies should be treated with urethroplasty, not further urethrotomy. A 2.5 cm bulbar stricture is amenable to excision and primary anastomosis (if truly short and not inflamed) or buccal mucosal graft augmentation if there is any concern about tension or length. Endoscopic options (optical urethrotomy, dilation, stents) are reserved for patients unfit for reconstruction or as temporising measures.

Technical considerations:

• Approach: Perineal approach with careful positioning; in an obese patient, adequate exposure may require a modified lithotomy position and attention to pressure areas and nerve injury.
• Graft vs anastomosis: Excision and primary anastomosis is suitable for a short bulbar stricture but must be tension-free; if there is any doubt, use a buccal mucosal graft (dorsal or ventral onlay) to avoid chordee and recurrence. Harvesting buccal mucosa adds a second operative site and needs its own consent.
• Vascularity: Preserve the bulbar arteries and avoid circumferential mobilisation that devascularises the repair.
• Urinary diversion: A suprapubic catheter is already in place; a urethral catheter may be placed across the repair for 2-3 weeks, or the repair can be drained suprapubically alone. The existing suprapubic tract can be used but should be revised if infected.
• Infection control: Optimise glycaemic control, treat urinary infection, and use antibiotic prophylaxis.
• Thromboprophylaxis and anaesthetic planning for obesity and diabetes.

Counselling:

• Success rates for bulbar urethroplasty are high (roughly 85-90% at 5 years for short bulbar strictures), but recurrence is possible and may need further intervention.
• Post-void dribbling, ejaculatory dysfunction and penile numbness or chordee are recognised complications; the patient should be warned.
• The suprapubic catheter can usually be removed once voiding is confirmed by a pericatheter or postoperative urethrogram and flow rate; he should understand that a period of catheterisation is unavoidable.
• Weight loss and glycaemic optimisation reduce wound complications and should be addressed before an elective procedure.
• Follow-up with uroflowmetry and symptom score, and a low threshold for imaging if symptoms recur.