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uro.urethral-stricture.v1

Urethral Stricture Disease (bulbar / penile / pan-urethral / LSA / iatrogenic / post-traumatic / pediatric / bladder-neck-contracture)

urologychronicsubacuteadultgeriatricpediatricoutpatientacuteinpatient
Start encounter →Print handoutPRODUCTION

Promoted SCAFFOLDED->INTEGRATED 2026-05-30. AUTHORED blocker (missing design_brief on disk) resolved by authoring src/lib/dossiers/_briefs/uro.urethral-stricture.v1.md. Evidence PMIDs PubMed-verified 2026-05-30: kept 27993339 (AUA Male Urethral Stricture Guideline, full metadata) + 27121095 (FQ safety); replaced 4 non-substantive/off-topic PMIDs (23416644 erratum, 27497791 comment letter, 25140208 ED-after-RP, 23764081 UroLift/BPH) with 25092646 (BMG urethroplasty), 25681241 (DVIU review), 21683406 (DVIU-recurrence RCT). PENDING PRODUCTION: RxNav-revalidate clobetasol 21655 + tamsulosin 77492; add calc.usd_lse / protocol.dviu / protocol.urethroplasty / workup.retrograde_urethrogram / workup.cystoscopy / panel.uroflow to registry; machine-validate terminology. Phase C wave-14 (2026-05-15): authored with full §5.5 depth — 11 phenotypes as severity_triggers, 5 settings (home/outpatient/ed/inpatient/icu), 1 regimen axis with 7 steps (dilation / DVIU / urethroplasty anastomotic+substitution+flap / LSA topical / BNC / pediatric / α-blocker bridge), sibling rows to real engines (uro.bph.v1, uro.post-prostatectomy-complications.v1, uro.uti.complicated.v1). AUA 2017 ladder: urethral dilation (short-term bridge) → DVIU (primary short bulbar; do NOT repeat) → urethroplasty (anastomotic short bulbar / substitution BMG long bulbar-penile / flap pan-urethral) + LSA clobetasol 0.05% BID × 12 wk + BNC endoscopic incision + pediatric post-hypospadias Bracka / BMG. Recurrent stricture after first DVIU → urethroplasty preferred (diminishing return on repeat DVIU). AUR with impassable Foley → STAT suprapubic catheter (do NOT force Foley); route to uro.acute-urinary-retention.v1. Sibling pivots: uro.bph.v1 (older man obstructive overlap), uro.post-prostatectomy-complications.v1 (post-RP BNC overlap), uro.uti.complicated.v1 (recurrent UTI structural factor) — all resolve to real engines in ALL_DOSSIERS. PMIDs marked NEEDS_SOURCE_REVIEW per shard convention; AUA urethral stricture 2017 / Wessells / post-RP BNC / EAU PMIDs are placeholders pending PubMed verification. Schema-blocked downstream: calc.usd_lse, protocol.dviu, protocol.urethroplasty, workup.retrograde_urethrogram (RUG), workup.cystoscopy, panel.uroflow — none yet in clinical-tools-registry.ts. Tickets surfaced in depth brief §6. Dossier registered in _registry.ts as part of this commit (Phase C wave-14 shard-3 scope).

Entry points (11)

  • symptom
    Progressive weak stream / hesitancy / straining / spraying / incomplete emptying — possible USD (AUA male urethral stricture 2017 PMID 27993339)
    weak_stream_or_obstructive_voiding
  • symptom
    Inability to void with palpable bladder — AUR; route to uro.acute-urinary-retention.v1 for STAT decompression
    acute_urinary_retention_with_stricture
  • history
    Recurrent UTI in adult man with weak stream → stricture workup; route to uro.uti.complicated.v1 overlap
    recurrent_uti_in_man_with_obstructive_voiding
  • history
    Prior straddle injury OR pelvic fracture → bulbar (straddle) or membranous (pelvic fracture urethral injury — PFUI) stricture
    post_traumatic_history_straddle_or_pelvic_fracture
  • history
    Iatrogenic — post-TURP / post-catheterisation / post-prostatectomy bladder-neck contracture (AUA 2017)
    iatrogenic_history_post_turp_post_catheter_post_RP
  • history
    Chronic gonorrhoeal / chlamydial urethritis history → inflammatory stricture (usually bulbar)
    post_sti_chronic_gc_or_chlamydia
  • history
    White plaques / scarring at meatus or glans — lichen sclerosus (LSA) — first line topical clobetasol
    lsa_meatal_or_distal_white_plaques
  • history
    Post-pelvic-radiation stricture (prostate / rectal / cervical) — challenging tissue bed
    post_radiation_pelvic
  • history
    Pediatric post-hypospadias repair stricture — specialised peds uro
    pediatric_post_hypospadias_repair
  • history
    Recurrent stricture after DVIU — DO NOT repeat DVIU >1; definitive urethroplasty
    failed_dviu_recurrent_stricture
  • problem_list
    Known USD followup — uroflow + IPSS + cystoscopy if symptoms recur
    known_stricture_surveillance

Required inputs (21)

  • sexrequired
    demographic • used at FRAME
    AUA scope is male urethral stricture; female urethral stricture is rare and out of scope here (route urogyn)
  • agerequired
    demographic • used at CONTEXT
    Pediatric post-hypospadias repair stricture pathway differs from adult bulbar / penile / pan-urethral (AUA 2017)
  • voiding_symptom_patternrequired
    symptom • used at ENTRY
    Obstructive predominant (weak stream / spraying / hesitancy / straining / dribbling) — differentiate from BPH (older patient) and overactive bladder (storage predominant) (AUA 2017)
  • ipss_scorerequired
    symptom • used at RISK_STRATIFICATION
    Severity stratification — IPSS 0–35; ≥20 severe; gates intervention urgency (AUA 2017)
  • acute_urinary_retentionrequired
    symptom • used at RED_FLAGS
    AUR with palpable bladder → STAT decompression (suprapubic if Foley-impassable); route uro.acute-urinary-retention.v1
  • trauma_history_straddle_or_pelvic_fracturerequired
    history • used at CONTEXT
    Bulbar (straddle injury) vs membranous PFUI (pelvic fracture) — phenotype + repair timing (AUA 2017)
  • iatrogenic_history_TURP_catheter_RPrequired
    history • used at CONTEXT
    Post-TURP, post-catheter, post-prostatectomy bladder-neck contracture differential; influences segment + treatment choice (AUA 2017)
  • sti_history_chronic_urethritis
    history • used at CONTEXT
    Chronic gonorrhoeal / chlamydial urethritis — inflammatory bulbar stricture phenotype; rare today with treatment but still relevant (CDC STI 2021)
  • lsa_lichen_sclerosus_historyrequired
    history • used at CONTEXT
    White plaques / phimosis / meatal scarring → LSA; topical clobetasol first-line; pan-urethral if extensive (AUA 2017)
  • pelvic_radiation_history
    history • used at CONTEXT
    Post-radiation stricture — challenging surgical bed; preferentially endoscopic management when possible (AUA 2017)
  • pediatric_hypospadias_repair_history
    history • used at CONTEXT
    Post-hypospadias-repair stricture is a pediatric uro subspecialty pathway (AUA 2017)
  • prior_dviu_or_dilation_countrequired
    history • used at CONTEXT
    Recurrent stricture after first DVIU has diminishing return — urethroplasty preferred over repeat DVIU (AUA 2017)
  • current_medsrequired
    history • used at CONTEXT
    Anticholinergics + decongestants worsen voiding; α-blocker trial may bridge symptoms; coumadin / DOAC affects surgical planning (AUA 2017)
  • retrograde_urethrogram_RUGrequired
    imaging • used at INITIAL_WORKUP
    RUG — gold-standard imaging to define stricture location, length, complexity; mandatory for surgical planning (AUA 2017)
  • voiding_cystourethrogram_VCUG
    imaging • used at INITIAL_WORKUP
    VCUG complementary — antegrade view especially for bladder-neck contracture and proximal stricture (AUA 2017)
  • cystoscopy
    imaging • used at INITIAL_WORKUP
    Cystoscopy — visual confirmation, calibre measurement, biopsy for LSA confirmation if atypical (AUA 2017)
  • uroflowmetryrequired
    imaging • used at INITIAL_WORKUP
    Qmax <15 mL/s consistent with obstruction; plateau / bell-shaped curve interpretation; serial monitoring (AUA 2017)
  • post_void_residualrequired
    imaging • used at INITIAL_WORKUP
    Elevated PVR (>100 mL) — clinically significant obstruction; gates AUR risk (AUA 2017)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Rule UTI before any instrumentation; treat infection before DVIU / urethroplasty (AUA 2017)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Baseline renal function; obstructive nephropathy if bilateral; pre-op clearance (AUA 2017)
  • temprequired
    vital • used at RED_FLAGS
    Fever + obstruction → urosepsis pathway; STAT decompression + IV abx (uro.uti.complicated.v1)

12-phase flow (12)

  1. 1FRAME
    Male patient (adult / geriatric / pediatric) with chronic obstructive voiding suggesting urethral stricture vs BPH vs prostate cancer vs urethritis. Female stricture rare → urogyn. Pediatric post-hypospadias repair stricture → peds uro subspecialty (AUA male urethral stricture 2017)
    inputs: sex, age
    advance: engine scope confirmed
  2. 2ENTRY
    Obstructive voiding pattern (weak stream / spraying / hesitancy / straining / dribbling); known trauma / iatrogenic / STI / LSA / radiation / hypospadias history; recurrent UTI; AUR (AUA 2017)
    inputs: voiding_symptom_pattern
    advance: entry captured
  3. 3CONTEXT
    Trauma history (straddle / PFUI), iatrogenic (TURP / catheter / RP), STI (chronic GC / chlamydia), LSA, pelvic radiation, prior DVIU / dilation count, pediatric hypospadias repair, current meds (AUA 2017)
    inputs: trauma_history_straddle_or_pelvic_fracture, iatrogenic_history_TURP_catheter_RP, sti_history_chronic_urethritis, lsa_lichen_sclerosus_history, pelvic_radiation_history, pediatric_hypospadias_repair_history, prior_dviu_or_dilation_count, current_meds
    advance: context complete
  4. 4RED_FLAGS
    AUR with palpable bladder → STAT suprapubic catheter (if Foley-impassable) → uro.acute-urinary-retention.v1; urosepsis (fever + obstruction) → ED + IV abx; obstructive AKI on labs → admit + urology + decompression; gross hematuria with stricture → cystoscopy + urgent uro (AUA 2017)
    inputs: acute_urinary_retention, temp
    advance: no red flags OR routes engaged
  5. 5INITIAL_WORKUP
    Retrograde urethrogram (RUG) — mandatory for surgical planning; voiding cystourethrogram (VCUG) for proximal / bladder neck; cystoscopy for visual + biopsy if LSA atypical; uroflowmetry + PVR + IPSS + QoL; UA + creatinine (AUA 2017)
    inputs: retrograde_urethrogram_RUG, voiding_cystourethrogram_VCUG, cystoscopy, uroflowmetry, post_void_residual, urinalysis, creatinine, ipss_score
    actions: panel.ua, panel.renal
    advance: imaging complete + segment / length / complexity assigned
  6. 6BRANCHING_WORKUP
    Stricture segment (bulbar vs penile vs pan-urethral vs membranous PFUI vs bladder-neck contracture) + length (short ≤2 cm vs long >2 cm) + aetiology (post-traumatic / iatrogenic / inflammatory STI / LSA / idiopathic / radiation / pediatric / failed DVIU); biopsy if LSA atypical or suspected SCC (rare); preoperative anesthesia + cardiac clearance (AUA 2017)
    advance: phenotype + complexity assigned
  7. 7DIFFERENTIAL
    USD vs BPH (older man, gradual onset, no trauma history) vs prostate cancer vs neurogenic bladder (DM / MS / CVA / cord) vs urethritis (acute STI) vs urethral cancer (rare, hematuria + mass on RUG) vs meatal stenosis (LSA distal) vs bladder-neck contracture (post-TURP / RP) (AUA 2017)
    advance: differential narrowed
  8. 8RISK_STRATIFICATION
    IPSS severity band, Qmax tier, PVR tier, anatomic complexity (length / location / aetiology), comorbidity overlay, prior DVIU count → urethroplasty candidacy (AUA 2017)
    advance: tier + surgical plan assigned
  9. 9TREATMENT
    STEP 1 — dilation OR DVIU for short ≤2 cm bulbar first-presentation. STEP 2 — urethroplasty (anastomotic for short bulbar; substitution / buccal mucosa graft for longer; staged / flap for pan-urethral). STEP 3 — LSA topical clobetasol 0.05% BID × 12 wk; meatoplasty / urethroplasty if refractory. STEP 4 — bladder-neck contracture endoscopic incision; AUS if continence-related. STEP 5 — pediatric post-hypospadias staged repair (peds uro). STEP 6 — α-blocker bridge (tamsulosin) for mild symptoms while awaiting definitive surgery (AUA 2017)
    inputs: current_meds
    advance: regimen / surgical plan documented
  10. 10DISPOSITION
    Outpatient primary + urology referral; ED for AUR / urosepsis; admit for post-op or severe AUR with renal failure; pediatric uro for post-hypospadias repair (AUA 2017)
    advance: disposition documented
  11. 11MONITORING
    IPSS + Qmax + PVR at 3, 6, 12 mo post-intervention; cystoscopy if symptoms recur; LSA — annual derm / uro for ongoing inflammation; AUR post-op — Foley duration + voiding trial (AUA 2017)
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Annual uroflow + symptom score; LSA lifelong derm surveillance; counsel recurrence rate (5-yr ~10% urethroplasty, 30–50% DVIU); pediatric — follow growth + repeat eval (AUA 2017)
    advance: follow-up + counselling complete