Urethral stricture disease, although common in the adult population, is quite rare in the pediatric population. Most treatment strategies are extrapolated from adult literature or from small case series of pediatric patients. A paucity of literature on pediatric stricture disease makes it difficult to create meaningful guidelines and/or treatment algorithms. In 2014, an initial attempt was made to generate guidelines for the management of pediatric urethral stricture disease; however, these were based on poor-quality existing evidence and are not universally followed.¹

Etiology of urethral stricture is similar to that of adults, with a few exceptions. Most common causes include hypospadias-associated (35%) and traumatic (34%) followed by congenital/idiopathic, iatrogenic (nonhypospadias), inflammatory, and postinfectious.² About two-thirds of strictures involve the anterior urethra, specifically the bulbar region. Straddle injuries with bulbar crush injuries are commonly seen in pediatric population.

Diagnosis of urethral stricture disease in children can be challenging. Diagnosis often requires a high index of clinical suspicion; patients often present with nonspecific voiding symptoms that can be misdiagnosed as dysfunction voiding. These symptoms include dysuria, urgency, incomplete emptying, hematuria, and stranguria. Diagnosis can be made with retrograde urethrogram, voiding cystourethrogram, or cystourethroscopy. In young children, retrograde urethrogram becomes technically challenging given short prepubertal penile length and may require sedation. Voiding cystourethrogram may also require sedation depending on the patient’s age and their tolerance to catheterization. Cystoscopy is often an initial choice because it can be both diagnostic and therapeutic. The surgeon can identify a stricture visually and then immediately perform endoscopic treatment. Notably, the 2014 guidelines questioned the utility of uroflowmetry, as some children had normal flow patterns despite the presence of a stricture. Moreover, it can be difficult to make younger children void on demand. Meatal stenosis typically presents with deflected or weakened stream, and is diagnosed on physical examination and clinical history, forgoing the need for further invasive testing.

Treatment of pediatric urethral strictures depends on the type of stricture, location, and length. Endoscopic treatment consists primarily of direct vision internal urethrotomy (DVIU) and can be performed as initial management for short anterior urethral strictures, typically < 1.5 cm in length. Success rates after DVIU vary from 26% to 62%.^3,4 In smaller children, DVIU can be performed using pediatric resectoscopes that vary between 8F and 9F in size or using a 15F adolescent resectoscope. Visualization with the smaller scopes can be hindering. DVIU can be performed with both cold-knife or laser fiber, with similar success rates. The benefits of DVIU are attributed to its minimally invasive nature and the ability to perform diagnostic cystoscopy and stricture treatment simultaneously under a single anesthetic. It may also act as a bridge to a more complex surgical repair, providing symptomatic improvement until a formal urethroplasty can be performed. While an initial DVIU has a modest success rate, we do not generally recommend repeat DVIU in pediatric patients as preliminary data suggest repeat DVIU has decreasing efficacy and durability. Additionally, patients with iatrogenic strictures from prior hypospadias repairs may fare better with urethroplasty reconstruction, as studies have shown significantly worse success rates for endoscopic management.⁵

In addition to endoscopic techniques, urethroplasty offers a durable surgical repair option for urethral strictures, particularly those strictures which are long or complex. Common urethroplasty techniques are similar to those used in adults. This includes excision and primary anastomosis, augmentation using buccal graft mucosa, flap techniques and staged Johanson repairs. Success rates are excellent, ranging from 82% to 100%.^6,7 Traditionally, hypospadias-associated strictures have been treated with upfront urethroplasty, whether single or staged repair. Hypospadias-associated stricture poses unique challenges given the nature of the disease and initial surgery to correct the urethra. Preliminary data at our institution may suggest a role for initial DVIU in select hypospadias-associated strictures. Notably, there has been no evidence to suggest that a prior DVIU would reduce the efficacy of urethroplasty. Because pediatric strictures are rare, pediatric urologists may not be as familiar with urethroplasty techniques; however, the skill set is similar to hypospadias reconstruction. Given that the techniques for pediatrics are not dissimilar to the adult urethral stricture repair, working alongside a local reconstructive urologist may improve patient outcomes.

In conclusion, pediatric urethroplasty is a rare etiology of voiding dysfunction in patients which requires a high index of suspicion. Once diagnosed, endoscopic options provide a moderate level of success with little to no morbidity, while formal urethroplasty reconstruction may yield higher success rates.