List of Abbreviations
IPSS - International Prostate Symptom Score
QoL - quality of life due to lower urinary tract symptoms
DVIU - direct visual internal urethrotomy
UTI – urinary tract infection
IIEF-5 – International Index of Erectile Function
ICD-10 – International Classification of Diseases 10th Revision
BL – bladder
MRI — magnetic resonance imaging
NSAIDs — nonsteroidal anti-inflammatory drugs
RPE – retropubic prostatectomy
AUR – acute urinary retention
LUTS – lower urinary tract symptoms
GR — Grade of Recommendation
LE — Level of Evidence
US — ultrasound
TPE – transvesical prostatectomy
PROM-USS - Patient-Reported Outcome Measure for Urethral Stricture Surgery
BXO – balanitis xerotica obliterans
obliterans).
HIFU (high-intensity focused ultrasound) – high-intensity focused ultrasound
Terms and Definitions
Augmentation urethroplasty – a reconstructive plastic surgery aimed at enlarging the lumen of the affected part of the urethra using a graft or a flap.
Bougie dilatation of the urethra — a palliative method of treating urethral strictures by stretching, dilation, or increasing the diameter of the urethral lumen in the area of narrowing using various methods (bougies, catheters, balloon dilators).
Direct visual internal urethrotomy (DVIU) – a minimally invasive palliative treatment for male urethral stricture, involving the incision of the urethral mucosa and scar tissue of the corpus spongiosum under optical control using various energy sources.
Urinary diversion – the drainage or redirection of urine from the urinary system bypassing the natural urinary tract via a surgical intervention, often utilizing an indwelling or catheterizable stoma.
Distraction urethral defect – partial or complete (obliteration) scar replacement of a membranous urethral defect resulting from partial or complete rupture due to pelvic fracture.
Substitutional (multi-stage) urethroplasty – a reconstructive plastic surgery in which a new urethral segment is formed to replace the diseased one, typically requiring two or more surgical stages.
Urethral calibration – measurement of the urethral lumen diameter by various methods, typically using sounds or catheters.
Flap – a segment of tissue harvested from a donor site while preserving its own blood supply via a vascular pedicle, used for transplantation to another, usually relatively adjacent, anatomical site.
Voiding cystourethrography (VCUG) – a radiographic imaging method of the urethra involving bladder filling with a contrast agent and taking an X-ray image during the act of micturition.
Urethral obliteration – complete absence of the urethral lumen due to spongiofibrosis and/or fibrosis of the periurethral tissues.
Perineostomy (perineal urethrostomy) – the most common type of urethrostomy, in which the proximal bulbar urethra relative to the stricture is brought out to the skin of the perineum without correcting the diseased part of the urethra.
Urethral resection with end-to-end anastomosis (anastomotic urethroplasty) – a reconstructive plastic surgery involving complete excision of the narrowed, scar-transformed urethral segment along with the pathologically altered corpus spongiosum and surrounding tissues, followed by an anastomosis between the healthy ends of the urethra.
Retrograde (ascending) urethrography – a radiographic imaging method of the urethra in which an iodine-containing radiocontrast agent is injected into the urethra through its external meatus under fluoroscopic control to obtain an image.
Spongiofibrosis - scarring changes of the corpus spongiosum of varying severity.
Urethral stenting – placement of a special device (stent) into the urethra to maintain the narrowed urethral segment in an expanded (open) state for an extended period.
Urethral stricture – narrowing of the urethra due to scarring of the urethral wall.
Graft – a segment of tissue harvested from a donor site without preserving its own blood supply and used for transplantation to another anatomical site. The graft receives blood supply via neoangiogenesis from the recipient tissue bed, and its viability primarily depends on the quality of the recipient vascular bed.
Ultrasound urethrography – an ultrasound imaging method of the urethra in which the urethra is filled with sterile saline, the external urethral meatus is occluded, and an ultrasound examination is performed using a linear probe with a frequency of 7 MHz or higher.
Urethrostomy – an anastomosis between the healthy suprastrictural part of the urethra and the skin surface for urinary diversion when restoration of anatomical urethral continuity is impossible.
Urethroplasty - various open, and much less frequently robot-assisted, plastic and reconstructive surgical interventions on the urethra aimed at eliminating its narrowing and restoring normal urine flow.
Urethrotomy - incision of a urethral segment (mucosa and underlying tissues) using endoscopic or open techniques.
Urethrocystoscopy - an endoscopic (transurethral) examination method of the lumen and mucosa of the urethra and urinary bladder.
Bladder neck sclerosis – narrowing of the bladder neck lumen caused by scarring.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Urethral stricture – narrowing of the urethra due to scarring of the urethral wall [1].
Bladder neck sclerosis – narrowing of the bladder neck lumen caused by scarring.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Etiology
traumatic
inflammatory (infectious and non-infectious)
iatrogenic
idiopathic
congenital
Comment: iatrogenic stricture may be both traumatic and inflammatory in its origin [1;4].
LE 4Grade of Recommendation D (Level of Evidence – 4)
Pathomorphosis
primary
recurrent [5;6].
LE 4Grade of Recommendation D (Level of Evidence – 4)
1.3 Epidemiology of the Disease or Condition
The incidence and prevalence of male urethral stricture in Russia are not precisely known. In the USA, the incidence of this condition was 274 cases per 100,000 healthcare visits. The incidence of urethral stricture increases with age, reaching 0.6% in men aged 65 to 69 years and 1.9% in those older than 85 years [7;8].
1.4 Features of Coding the Disease or Condition
N35.0 - Post-traumatic urethral stricture.
N35.1 - Postinfection urethral stricture, not elsewhere classified.
N35.8 - Other urethral stricture.
N35.9 - Urethral stricture, unspecified.
N99.1 - Postprocedural urethral stricture.
N32.0 - Bladder-neck obstruction
1.5 Classification of the disease or condition
The clinical presentation is characterized by lower urinary tract symptoms of varying severity:
weak urinary stream and reduced urinary volume;
dysuria (pain during urination);
feeling of incomplete bladder emptying;
urinary frequency;
inability to control urination (incontinence);
pelvic and lower abdominal pain syndrome;
localized pain in the penis;
acute urinary retention
recurrent urinary tract infection [1;5;6].
1.6 Clinical presentation of the disease or condition
Etiology
traumatic
inflammatory (infectious and non-infectious)
iatrogenic
idiopathic
congenital [1;4].
Localization
bladder neck
prostatic
membranous
bulbar
penile
glanular
navicular fossa
external urethral meatus
Length
short (≤ 2 cm)
long (> 2 cm)
total spongy (involvement of more than 75% of the spongy urethra)
total (involvement of the entire urethra) [3;4].
Quantity
single
multiple
Comment: Each stricture of the urethra in multiple strictures may have a different etiology, localization, and length.
Degree of contraction
mild – lumen narrowed up to 50%
moderate – lumen narrowed up to 75%
severe – lumen narrowed > 75%
obliteration – lumen absent [3].
Comment: every patient should be evaluated for all classification factors, as they not only determine the severity of the disease but also influence the choice of treatment method. When formulating a diagnosis, it is not necessary to indicate all classification characteristics, but only the main ones: etiology, localization, and length of the stricture.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for establishing the disease or condition:
Presence of a narrowing less than 16 CH or urethral obliteration confirmed by retrograde urethrography and urethroscopy.
Presence of an obstructive (platelet/flat) urinary flow curve during uroflowmetry.
2.1 Complaints and Anamnesis
When taking the history, it is recommended to check for the following symptoms in all patients:
o Dysuria (difficulty urinating);
o Weak urinary stream;
o Feeling of incomplete bladder emptying;
o Periodic urinary retention;
o Urinary incontinence during physical exertion, coughing, walking, or after urination;
o Urgency with accompanying urinary incontinence;
o Pain and discomfort before, during, and after urination [6;9;10;11].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5)
When taking the medical history, it is recommended to obtain the following information from all patients:
o Bladder drainage with a urethral catheter;
o Traumatic urethral catheterization;
o Transurethral manipulations and/or surgeries;
o Blunt perineal trauma (straddle injury, falling onto or blow to the perineum);
o Penetrating perineal trauma (stab or gunshot wound);
o Pelvic bone fracture (from a fall from height or in road traffic accidents);
o Previous sexually transmitted infections (gonorrhea, etc.);
o Genital lichen sclerosus;
o Circumcision;
o Hypospadias repair surgeries;
o Previous surgeries and manipulations (bougienage) for urethral stricture.
o Prior radiation therapy for pelvic malignancies.
o Previously used high-energy treatment modalities for prostate cancer (cryotherapy, radiofrequency ablation, high-intensity focused ultrasound or HIFU ablation).
o Introduction of foreign bodies or caustic liquids into the urethra (silver nitrate solutions, alcohol chlorhexidine, etc.).
o Sexual history analysis
o Coital trauma [6;9;10;11].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
2.2 Physical Examination
Physical examination helps determine factors that influence the choice of patient management tactics.
It is recommended that all patients undergo an examination and assessment of:
o Penis
o External urethral meatus
o Presence or absence of foreskin changes
o Assessment of the perineum
o Palpation of the urethra and scrotal organs
o Assessment of postoperative scars and urethrovaginal/urethrocutaneous fistulae
o Urethral discharge
o Assessment for signs of Lichen Sclerosus
o Digital rectal examination
o Oral cavity examination
o Examination of the suprapubic cystostomy drainage site (if present)
o Assessment of hip and knee joint mobility [1;12;13].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comment: physical examination helps evaluate the etiological factor of urethral stricture, previous surgical interventions, potential surgical access routes, the condition of tissues for subsequent surgeries, and the presence of complications associated with urethral stricture disease.
2.3 Laboratory Diagnostics
There are no specific laboratory diagnostic methods for detecting urethral stricture.
For additional assessment of the urogenital system, it is recommended that all patients undergo:
o Complete blood count (CBC) [12;13];
o Urine culture and susceptibility testing for aerobic and facultatively anaerobic opportunistic pathogens [14;15];
o Complete blood count [12;13];
o Routine biochemical blood test [12;13];
o Blood test for total prostate-specific antigen (in patients with risk or presence of oncological disease) [14;15].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comment: laboratory test results allow for the evaluation of renal filtration and excretory function (creatinine and urea levels). In the presence of inflammatory conditions, blood tests show an increase in acute-phase reactants (leukocytes, C-reactive protein, ESR). Urine culture with antibiogram enables adequate antibiotic prophylaxis and therapy according to the risk stratification of infectious complications and helps prevent surgical site infection.
2.4 Instrumental Diagnostics
2.4.1 Non-invasive special diagnostics
It is recommended that all patients complete validated questionnaires to assess lower urinary tract symptoms (LUTS), such as the International Prostate Symptom Score (IPSS) [17;18].
GRC CLeE 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended that all patients complete the IIEF-5 questionnaire to assess erectile function [19].
GRC CLeE 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended that all patients with lower urinary tract symptoms (LUTS) undergo uroflowmetry; data are considered reliable at a voided volume of more than 120 ml [16].
Level of Recommendation CLevel of Evidence 4Level of Recommendation C (level of evidence – 4)
It is recommended to perform ultrasound examination of the kidneys and bladder with residual urine volume measurement to assess concomitant pathology [13].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: uroflowmetry is an indispensable diagnostic method for a patient with urethral stricture and preserved spontaneous voiding capacity, both prior to surgery and during follow-up. Based on the urine flow rate curve shape, uroflowmetry allows for a preliminary determination of the cause of voiding dysfunction: urethral stricture, benign prostatic hyperplasia, bladder neck sclerosis, or neurogenic voiding disorders. Validated questionnaires not only allow for the assessment of the severity of lower urinary tract symptoms before surgery but also serve as a tool for postoperative monitoring.
2.4.2 Invasive special diagnostics
The primary diagnostic method for urethral stricture is ascending urethrography. Auxiliary methods also include voiding cystourethrography, combined (evacuating + ascending) cystourethrography, and fistulography.
It is recommended to perform retrograde urethrography in all patients with suspected urethral stricture, except for patients with contrast media hypersensitivity [1;11;18;19].
GRC CLeE 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to perform fistulography in all patients presenting with a fistula [67].
Level of Evidence CGrade of Recommendation 5Level of recommendation confidence C (level of evidence – 5)
It is recommended to perform retrograde urethrocystoscopy and antegrade cystourethroscopy only when urethrography does not provide accurate information [1;13;20;21].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: Radiological and endoscopic diagnostic methods provide information on the location and length of the urethral stricture.
2.5 Other Procedures
To further evaluate urethral stricture and the degree of spongiofibrosis, it is recommended to perform ultrasound examination of the urethra [22].
GCR BLEL 2Grade of Recommendations B (Level of Evidence – 2)
In the diagnosis of complicated posterior urethral stenoses, it is recommended to perform contrast-enhanced pelvic MRI [23].
GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3)
Comment: MRI provides a clearer and more accurate visualization of associated pathologies, such as fistulas (urethrorectal and vesicosymphyseal), pathological cavities, and diverticula, and allows for a more precise determination of their location in a three-dimensional image.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Urethral dilation.
Urethral dilation is a palliative method of treating urethral strictures by stretching, dilating, or increasing the diameter of the urethral lumen in the area of narrowing using various methods (bougies, catheters, balloon dilators).
Urethral dilation as a treatment method is recommended in patients with contraindications to surgical treatment. The efficacy of urethral dilation is comparable to that of direct vision internal urethrotomy (DVIU) [27;28].
GGR CLOC 5Grade of Recommendation C (Level of Evidence – 5).
Comment: urethral dilation is not a curative method.
It is not recommended to perform urethral dilation if end-to-end anastomotic urethroplasty or another method of urethroplasty is feasible [29].
GGR CLOC 5Grade of Recommendation C (Level of Evidence – 5).
Comment: during urethral dilation along with expanding the lumen of the altered part of the urethra, micro-tears of the epithelial layer and scar occur, which leads to worsening of spongiofibrosis and may lead to shortening of intervals between dilations. Urethrorrhagia is a contraindication to urethral dilation.
3.2 Direct vision internal urethrotomy.
Direct vision internal urethrotomy (DVIU) is a minimally invasive palliative treatment for male urethral stricture, in which the urethral mucosa and the scar zone of the corpus spongiosum are incised under optical control using various types of energy.
It is recommended to perform DVIU for primary non-traumatic strictures of the bulbar urethra up to 1 cm in length [31;32].
GCP CLoE 4Grade of Recommendation C (Level of Evidence – 4).
It is not recommended to perform DVIU for primary urethral strictures greater than 1 cm or for penile urethral strictures of any length [29;30].
GCP CLoE 4Grade of Recommendation C (Level of Evidence – 4).
It is not recommended to perform DVIU for recurrent urethral strictures after 2 previous DVIU procedures [31;33].
GCP CLoE 4Grade of Recommendation C (Level of Evidence – 4).
The use of pharmacological agents to improve DVIU outcomes currently lacks sufficient scientific evidence, and their use is recommended only in scientific and experimental studies [35;36].
GGR CLOC 5Grade of Recommendation C (Level of Evidence – 5).
Comment: Laser DVIU may have a slight advantage over cold knife incision [34].
3.3 End-to-end anastomotic urethroplasty.
End-to-end anastomotic urethroplasty is a reconstructive-plastic surgery involving the complete excision of the narrowed, scar-transformed segment of the urethra along with the pathologically altered corpus spongiosum and surrounding tissues, followed by an anastomosis between the healthy ends of the urethra. This surgery can be performed with complete or incomplete transection of the corpus spongiosum.
End-to-end anastomotic urethroplasty is recommended for strictures and obliterations of:
- the bulbar urethra up to 4 cm in length,
- the membranous urethra,
- the membranoprostatic urethra,
- the prostatic urethra [37].
GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4).
It is not recommended to perform end-to-end urethroplasty for penile urethral strictures of any length [38].
GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4).
Comment: it is important to perform the urethral anastomosis without tension to prevent ischemia of the urethral wall and subsequent stricture recurrence. For strictures >2 cm in length, end-to-end anastomotic urethroplasty may lead to an increased recurrence rate, penile shortening, and penile curvature.
3.4 Augmentation urethroplasty.
Augmentation urethroplasty is a reconstructive-plastic surgery in which the lumen of the affected part of the urethra is enlarged using a graft or flap.
It is recommended to use augmentation urethroplasty techniques for penile urethral strictures [39].
GRC CLeE 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to use augmentation urethroplasty techniques for bulbar urethral strictures longer than 2 cm [39].
GRC CLeE 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to use oral mucosa as the primary graft instead of a skin graft [40].
GGR BLOC 2Grade of Recommendation B (Level of Evidence – 2)
It is recommended to use an oral graft or skin flap as a plastic material for augmentation urethroplasty, as both techniques show comparable efficacy [41;42].
GGR CLEL 3Grade of Recommendation C (Level of Evidence — 3)
It is not recommended to use skin flaps in lichen sclerosus [43].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to prefer the dorsal graft fixation technique for penile urethral strictures [44;45].
GGR BLOC 2Grade of Recommendation B (Level of Evidence – 2)
It is recommended to use dorsal or ventral graft fixation techniques for bulbar urethral strictures [44;45].
CGR BLEL 2Level of Clinical Guidance Recommendation B (Level of Evidence – 2).
3.5 Substitution Urethroplasty.
Substitution (multi-stage) urethroplasty is a reconstructive plastic surgery procedure that involves forming a new urethral segment to replace the affected one, usually requiring two or more surgical stages
Multi-stage urethroplasty is recommended for long obliterating strictures of the anterior urethra [46;47].
GPP CLOE 4Strength of Recommendation C (Level of Evidence – 4)
Multi-stage urethroplasty is recommended for long urethral strictures with severe spongiofibrosis, local tissue deficiency, or lichen sclerosus [39;48;66].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5)
Multi-stage urethroplasty is recommended for long strictures of the neourethra following hypospadias repair [39;49;66].
GPP CLOE 4Strength of Recommendation C (Level of Evidence – 4)
The final stage of multi-stage urethroplasty is recommended to be performed no earlier than 6 months after the previous stage [39;50;66].
GPP CLOE 4Strength of Recommendation C (Level of Evidence – 4)
Comment: in some patients after the 1st stage, contraction (shrinking) of the new urethral plate (graft) may occur, which requires a repeat surgery to correct the urethral plate before the final stage (urethral tubularization).
3.6 Perineostomy.
Perineostomy (perineal urethrostomy) is the most common type of urethrostomy, in which the segment of the bulbar urethra proximal to the stricture is brought out to the perineal skin without correcting the affected part of the urethra.
Perineostomy is recommended for primary urethral strictures in patients with significant comorbidities as a simpler alternative to augmentation and substitution urethroplasty methods [52].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5)
Perineostomy is recommended for urethral strictures in patients who do not wish to undergo substitution urethroplasty [51;52].
GPP CLOE 4Strength of Recommendation C (Level of Evidence – 4)
Comment: when performing perineal urethrostomy, tension between the perineal skin edges and the healthy urethral edges must be avoided to reduce the risk of perineostomy stenosis.
3.7 Complex cases of strictures and posterior urethral obliterations
Rare and complex lesions of the posterior urethra include, but are not limited to: vesicourethral anastomotic stenosis (VUAS) after radical prostatectomy, posterior urethral injuries after rectal surgery, loss (obliteration) of an extensive segment of the posterior urethra resulting from trauma, prior surgeries, radiation therapy for prostate cancer, thermal and chemical urethral burns, and blast injuries of the urethra.
It is recommended to perform surgical treatment of complex clinical cases of strictures and obliterating lesions of the posterior urethra in specialized reconstructive urology centers [62].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to use transperineal, prerectal, retropubic, suprapubic, and combined surgical approaches and their combinations, as well as specialized instruments [62].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to excise extensive segments of the affected urethra and periurethral tissues, and to use muscle, fascial, and adipose flaps to ensure the presence of well-vascularized tissues in the urethroplasty area to serve as a vascularized bed for grafts or as tissue interposition layers in the presence of fistulas [64].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to use combinations of various urethroplasty techniques to form a urethrovesical anastomosis or to apply complex substitution urethroplasty methods [65].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to use bladder and supravesical urinary diversion methods in cases where urethral reconstruction is impossible [62].
GRC CLEL 5Grade of Recommendation C (Level of Evidence – 5)
3.8 Urethral Distraction Defect Following Pelvic Fracture.
Urethral distraction defect is partial or complete (obliteration) scar substitution of a membranous urethral defect as a result of its partial or complete rupture due to a pelvic fracture.
It is recommended in case of posterior urethral trauma due to a fracture to perform trocar cystostomy or endoscopic-assisted urethral catheter placement [69].
GCP CLoE 4Grade of Recommendation C (Level of Evidence – 4).
It is recommended to perform delayed urethroplasty after the removal of hardware and when the patient is able to tolerate the lithotomy position [71].
GCP CLoE 4Grade of Recommendation C (Level of Evidence – 4).
It is not recommended to use endoscopic methods (dilation or DVIU) in the delayed treatment of a urethral distraction defect [70].
GCP CLoE 4Grade of Recommendation C (Level of Evidence – 4).
It is recommended to perform resection urethroplasty (bulboprostatic anastomosis) in all cases of urethral distraction defect, which must include complete scar excision and spatulation of the proximal and distal urethral ends [69].
GCP CLoE 4Grade of Recommendation C (Level of Evidence – 4).
It is recommended to use the following sequential surgical steps to reduce tension at the anastomotic site: mobilization of the bulbar urethra, separation of the crura of the corpora cavernosa, inferior pubectomy, and supracrural rerouting [2;69].
GCP CLoE 4Grade of Recommendation C (Level of Evidence – 4).
It is recommended to refer patients to specialized urological centers for surgical treatment [52].
GGR CLOC 5Grade of Recommendation C (Level of Evidence – 5).
Comment: Preoperative evaluation of patients with urethral injury caused by pelvic fracture should include retrograde urethrography, voiding cystourethrography, and antegrade cystourethroscopy to assess the boundaries of the urethral narrowing (obliteration), the degree of displacement of the urethra and bladder neck relative to the symphysis. The voiding cystourethrogram may include a static cystogram phase to evaluate the competence of the bladder neck closure mechanism and the position of the bladder neck relative to the pubic symphysis. Additional imaging methods: CT cystourethrography or pelvic MRI can be performed to assess urethral patency proximal to the defect and to determine the anatomical characteristics of the injured urethra.
Surgical treatment of urethral strictures associated with pelvic ring fracture and internal fixation is advisable after the removal of the hardware fixing the pelvic bones, since excessive retropubic protrusion of screws is associated with an extensive area of periurethral fibrous and inflammatory damage and entails risks of recurrence if urethral surgery precedes hardware removal.
3.9 Bladder Neck Contracture (Urethrovesical Anastomotic Stenosis).
Bladder neck contracture (urethrovesical anastomotic stenosis) represents scar transformation and narrowing of the urethral and bladder neck anastomosis up to complete obliteration.
Comment: Bladder neck contracture (BNC) is a relatively rare complication of the surgical treatment of prostate cancer (PCa), specifically radical prostatectomies (RP), occurring in 2.7 to 15% of cases following various techniques of this surgical intervention [79].
It is recommended to perform internal (transurethral) urethrotomy using a cold knife or laser energy, but no more than two procedures [24].
GCP CLoE 4Grade of Recommendation C (Level of Evidence – 4).
Comment: The recurrence rate after endoscopic corrections is quite high, reaching 34% at 1 year after surgery and 42% at 5 years, which suggests against performing multiple endoscopic corrections in patients with VUAS and limiting them to no more than two procedures. Failed endoscopic corrections lead to the formation of more extensive and dense scar tissue in the stricture/stenosis area and complicate subsequent effective urethral reconstruction. The latter can be performed via perineal, robot-assisted, laparoscopic, and retropubic approaches [80].
If endoscopic surgery is ineffective, it is recommended to perform surgical reconstruction of VUAS via perineal, retropubic, abdominoperineal, and robotic approaches [25;26;80].
GCR BLEL 2Grade of Recommendation B (Level of Evidence – 2).
It is recommended to perform repeat re-anastomosis of the urethra and bladder neck in patients after multiple failed endoscopic corrections who have not received radiation therapy, or in those who received it and have normal bladder function [26].
GCP CLoE 4Grade of Recommendation C (Level of Evidence – 4).
Comment: regardless of the approach, the essence of the surgery is the excision of scar tissue of the bladder neck and urethra and the creation of a repeated vesicourethral anastomosis between healthy tissues of the urethra and the bladder neck without excessive tension. In addition to anastomotic urethroplasties, some authors have reported the use of augmentation urethroplasty using oral mucosa for bladder neck stenosis. The scope of surgery depends on the length of the stenosis, the functional state of the external urinary sphincter and bladder, a history of adjuvant pelvic radiation therapy, and the presence of a urethrogram-proven or suspected rectourethral fistula. The efficacy of surgical reconstruction of vesicourethral stenosis according to various authors ranges from 60 to 91%. It is important to note that, especially when using a perineal approach, almost all operated patients develop urinary incontinence, which requires a second-stage implantation of an artificial urinary sphincter.
3.10 Bladder neck sclerosis
Bladder neck sclerosis – critical narrowing of the bladder neck lumen caused by a scarring process.
It is recommended to perform endoscopic transurethral incision of the bladder neck for primary or recurrent bladder neck sclerosis [73, 72].
GPP CLEL 4Level of Evidence Recommendation C (Level of Evidence – 4)
Comment: The recurrence rate of bladder neck sclerosis increases with the number of surgeries. After 4 or more surgeries, the efficacy is up to 25%. Bladder neck sclerosis occurs more frequently in small prostates after both monopolar and bipolar transurethral resection of the prostate (TURP).
It is recommended to perform balloon dilation of the bladder neck for primary or recurrent bladder neck sclerosis [72].
Level of Recommendation CLevel of Evidence 4Level of Recommendation C (level of evidence – 4)
It is recommended to perform VY bladder neck plasty for frequently recurrent (more than 4 times) bladder neck sclerosis [68].
GCR BLoE 3Level of Evidence B (Level of Confidence of Evidence – 3)
3.11 Regenerative medicine in the treatment of urethral strictures.
3.11.1 Platelet-rich plasma.
It is recommended to use platelet-rich plasma in the treatment of urethral stricture as part of research studies [77; 78].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5)
Comment: Platelets contain high concentrations of growth factors such as PDGF-AB (platelet-derived growth factor AB), TGF-$eta$1 (transforming growth factor beta 1), and VEGF (vascular endothelial growth factor). These factors can stimulate cellular proliferation and angiogenesis and reduce the inflammatory process. The use of platelet-rich plasma in reconstructive urethral surgery has good prospects and requires further study.
3.11.2 Stromal vascular fraction.
It is recommended to use the stromal vascular fraction in the treatment of urethral stricture as part of research studies [60; 61; 81].
GGR CLOC 5Grade of Recommendation C (Level of Evidence – 5).
Comment: Studies have demonstrated the differentiation properties of SVF, its regenerative potential [1, 8-10], stimulation of angiogenesis, and immunomodulatory properties. High-quality studies proving the efficacy of SVF and cellular technologies in general are required; the method can be potentially safe and effective, allowing for improved surgical treatment outcomes in patients with urethral diseases.
3.12 Pharmacotherapy in the treatment of urethral strictures.
Pharmacotherapy in the treatment of urethral strictures – adjuvant injection of a pharmaceutical agent to reduce fibroblast proliferation and excessive scarring of the urethra.
It is recommended to use systemic corticosteroids (H02A) in the endoscopic treatment of urethral stricture only within clinical trials [75].
GRB BLoE 1Grade of Recommendation B (Level of Evidence – 1)
Comment: In a 2014 meta-analysis, there were no statistically significant differences in recurrence rates between the steroid group and the control group, respectively. The time to recurrence was significantly longer in the steroid group. No significant differences were found in the rate of complications (infection, bleeding).
It is recommended to use #mitomycin 0.05 mg/ml in the endoscopic treatment of urethral stricture only within clinical trials [76].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comment: the use of #mitomycin 0.05 mg/ml was associated with the lowest rate of urethral stricture recurrence. The efficacy of mitomycin 0.05 mg/ml was higher for strictures less than 2 cm and with a follow-up of more than 12 months. In the absence of well-conducted and adequate RCTs, as well as a lack of standardization (dose, technique, volume, etc.), more rigorous clinical studies are required.
3.13 Tissue engineering.
It is recommended to use tissue-engineered constructs (cellular and acellular matrices) in the treatment of urethral stricture only within clinical trials [3; 56; 57].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5)
Comment: A systematic review revealed that their overall level of evidence is quite low due to high heterogeneity in patient selection criteria, surgical techniques used, study design, and follow-up period.
However, further clinical trials are necessary to establish the specific features of using other materials (including when seeded with cells) and to identify optimal indications for surgeries involving them.
Due to growing interest and an increasing number of studies on tissue engineering, there is a need in the near future to develop a clear and precise regulatory framework for tissue equivalents.
3.14 Urethral stents.
It is recommended to use a long-term polymer urethral stent*** only as a palliative treatment method for urethral stricture with high risks of complications [58; 59].
GCP CLoE 4Grade of Recommendation C (Level of Evidence – 4).
In case of placement of a long-term polymer urethral stent***, it is recommended to give preference to non-metallic biodegradable stents [58; 59].
GCP CLoE 4Grade of Recommendation C (Level of Evidence – 4).
Comment: Long-term polymer urethral stents*** are not a first-line method, but may be indicated for patients with comorbidities and recurrent stricture after internal optical urethrotomy/dilation if more complex urethroplasty is impossible or refused by the patient. The patient must be informed about the risks and complications of urethral stent implantation.
The most common complications of urethral stent placement are encrustation, migration, and urinary incontinence.
An experimental study evaluated the efficacy of novel drug-eluting (paclitaxel) biodegradable urethral stents in the treatment of urethral stricture. Data on safety and efficacy in treating urethral strictures in an animal model were obtained. Further clinical practice studies with larger sample sizes and longer follow-up durations are needed.
3.15 Postoperative follow-up.
It is recommended to perform urethrography to assess healing in the urethroplasty area after 7–28 days, depending on the surgical method used [13; 53; 54].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5)
It is recommended to resume spontaneous urination in the absence of contrast agent extravasation into the periurethral tissues on urethrography [13; 53; 54].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5)
Uroflowmetry is recommended to monitor the efficacy of the surgery [53; 54].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5)
If adequate urination is not restored, it is recommended to keep the existing cystostomy tube, or if absent, a trocar cystostomy is recommended [1; 5; 55].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comment: in case of prolonged (more than 4 weeks) contrast agent extravasation, fistulous tract formation, or infectious complications (acute prostatitis, orchiepididymitis, wound suppuration), patients are recommended to undergo trocar cystostomy and removal of the urethral catheter. Repeat retrograde urethrography is performed 2–3 weeks after complication management [1; 13].
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Not provided.
5. Prevention and Dispensary Observation
Long-term follow-up (at least 1 year) is recommended for patients who have undergone various types of surgical interventions on the urethra [13; 53; 54; 55].
GPP CLOE 4Strength of Recommendation C (Level of Evidence – 4)
It is recommended to assess quality of life and lower urinary tract symptoms using validated questionnaires (IPSS, PROM-USS) and to evaluate sexual function (IIEF-5) [17; 18].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
6. Organization of Medical Care
Stages of medical care delivery:
1. Pre-hospital outpatient stage.
2. Planned hospitalization for surgical treatment, including additional instrumental examinations and surgery in the absence of contraindications.
3. Discharge from the medical organization for outpatient follow-up according to recommendations.
Indications for hospitalization in a medical organization:
1. Planned hospitalization: presence of a urethral stricture diagnosis confirmed by retrograde urethrography, uroflowmetry, urethrocystoscopy, or clinical presentation.
2. Emergency hospitalization: acute or chronic urinary retention.
Indications for hospital discharge
1.Patient discharge is possible on days 1–7 after diagnostic procedures or surgical treatment, provided the patient's condition is satisfactory, there are no signs of surgical site infection, hyperthermia, or urinary tract infection, and spontaneous urination has recovered or adequate temporary or permanent bladder drainage is established.
2. Patients may be discharged from the hospital with a urethral and/or suprapubic catheter, followed by outpatient monitoring according to the guidelines.
7. Additional Information
Not applicable.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Level reliability evidence | Level convincingness |
|---|---|---|---|
1 | Performance of retrograde urethrography | 4 | C |
2 | General clinical urinalysis performed | 4 | C |
3 | Uroflowmetry performed | 4 | C |
4 | Ultrasound examination of the kidneys and bladder with residual urine volume measurement is recommended to assess concomitant pathology | 4 | C |
5 | Urethrography performed 7–28 days postoperatively | 4 | C |
6 | Uroflowmetry performed to evaluate treatment efficacy | 4 | C |
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Appendix A1. Working Group Composition
Mikhail I. Kogan — Doctor of Medical Sciences, Professor, Head of the Department of Urology and Human Reproductive Health with the Course of Pediatric Urology-Andrology, Faculty of Advanced Training and Professional Retraining of Physicians at Rostov State Medical University, Director of the Research Institute of Urology and Nephrology at Rostov State Medical University.
Kotov, Sergey Vladislavovich – Doctor of Medical Sciences, Professor, Head of the Department of Urology and Andrology, Faculty of General Medicine, Pirogov Russian National Research Medical University of the Russian Ministry of Health.
Zhivov, Alexey Viktorovich – Candidate of Medical Sciences, Associate Professor at the Department of Urology, A.I. Evdokimov Moscow State University of Medicine and Dentistry.
Mitusov, Valery Viktorovich – Doctor of Medical Sciences, Professor at the Department of Urology and Human Reproductive Health with the Course of Pediatric Urology-Andrology and Faculty of Advanced Training and Professional Retraining of Specialists, Rostov State Medical University.
Glukhov, Vladimir Pavlovich – Candidate of Medical Sciences, Associate Professor at the Department of Urology, Faculty of Advanced Training and Professional Retraining of Specialists, Rostov State Medical University.
Iritsyan, Mikhail Matevosovich – Candidate of Medical Sciences, Assistant Professor at the Department of Urology and Andrology, Faculty of General Medicine, Pirogov Russian National Research Medical University of the Russian Ministry of Health.
Kazikhinurov, Rustem Alfredovich – Candidate of Medical Sciences, Associate Professor at the Department of Urology with the Course of the Institute of Additional Professional Education.
Butnaru, Denis Viktorovich – Doctor of Medical Sciences, Deputy Director for Scientific Affairs, Research Institute of Uronephrology and Reproductive Health.
Conflict of interest: All Working Group members have confirmed the absence of financial support / conflicts of interest that need to be disclosed.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines - specialists with higher medical education in the following specialties:
1. Urology
2. Therapy
3. General practice (family medicine)
4. Gerontology
5. Surgery
In these clinical guidelines, all information is ranked by the level of reliability (evidence) depending on the quantity and quality of studies on the issue.
Table A.1 – Scale for assessing levels of reliability of evidence (LRE) for diagnostic methods (diagnostic interventions)
Category | Evidence |
|---|---|
1 | Systematic reviews of studies with reference method controls or systematic reviews of randomized clinical trials using meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table A.2 – Scale for assessing levels of reliability of evidence (LRE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
Category | Evidence |
|---|---|
1 | Systematic review of randomized controlled trials with meta-analysis |
2 | Individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table A.3 – Scale for assessing levels of recommendation persuasiveness (LRP) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
Level | Bases |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Appendix A3. Reference Materials
These clinical guidelines were developed taking into account the following regulatory and legal documents:
1. American Urological Association Clinical Guidelines 2016.
2. Order of the Russian Ministry of Health No. 907n dated November 12, 2012, “On approval of the procedure for providing medical care to the adult population in the specialty ‘urology’.”
3. Order of the Ministry of Health of the Russian Federation No. 103n dated February 28, 2019, “On approval of the procedure and timelines for the development of clinical guidelines, their revision, standard form of clinical guidelines, and requirements for their structure, composition, and scientific validity of information included in clinical guidelines.”
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Urethral stricture is a narrowing of the urethra resulting from cicatricial lesions of the urethral wall.
You should consult a urologist if you develop one or several of the following symptoms:
weak urinary stream;
dysuria (pain during urination);
feeling of incomplete bladder emptying;
urinary frequency;
inability to control urination (incontinence);
pelvic and lower abdominal pain syndrome;
localized pain in the penis;
Acute urinary retention.
Diagnosis in the presence of lower urinary tract symptoms includes:
Completion of validated questionnaires;
Ultrasound examination of the urinary system;
Uroflowmetry and post-void residual urine assessment;
Urodynamic study (if necessary).
Uroflowmetry is an indispensable diagnostic method for the patient before surgery and during follow-up monitoring after it. Based on the shape of the urinary flow rate curve, uroflowmetry makes it possible to preliminarily determine the cause of voiding dysfunction: urethral stricture, benign prostatic hyperplasia, bladder neck sclerosis, neurogenic voiding disorders.
Validated questionnaires not only allow assessing the severity of lower urinary tract symptoms before surgery, but also serve as a monitoring tool after it.
If urethral stricture is suspected, the patient undergoes retrograde urethrography, and for additional information – voiding cystourethrography or urethrocystoscopy.
After confirmation of the diagnosis of urethral stricture, surgical treatment is required according to the etiology, location, and length of the urethral stricture.
Surgical treatment of complex urethral stricture cases should be performed in expert centers.
Following surgical treatment, most patients are discharged with a urethral or cystostomy catheter for a period of 7 to 28 days or longer for outpatient management.
You should consult the urologist at the clinic where the urethroplasty was performed in case of:
Fever (a sign of a urinary tract infection);
Inadequate bladder drainage via the catheter (heavy urine leakage around the catheter);
Heavy discharge from the urethra or the surgical wound area and/or a foul odor (a sign of infection);
Following successful surgical treatment, the patient needs follow-up evaluations at 1, 3, 6, 9, and 12 months during the first year after surgery, and thereafter annually, as disease recurrence can occur at later dates.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Appendix G1. International Prostate Symptom Score.
Russian title: International Prostate Symptom Score
Original title (if any): International Prostate Symptom Score
Source (official developer website, validation publication): https://uro-info.ru/tests/mezhdunarodnaya-sistema-summarnoy-otsenki-zabolevaniy-predstatelnoy-zhelezy-v-ballakh-ipss.
Original: Barry, M.J., Fowler, F.J., O"leary, M.P., Bruskewitz, R. C., Holtgrewe, H. L., Mebust, W. K., & Cockett, A. T. K. (2017). The American Urological Association Symptom Index for Benign Prostatic Hyperplasia. The Journal of Urology, 197(2), S189-S197. doi:10.1016/j.juro.2016.10.071
Type (underline):
- rating scale
- index
- questionnaire
Purpose: Assessment of lower urinary tract symptoms
Content (template):
I-PSS scale | Never | Less than 1 time in five | Less than half the time | Approximately in the time | More often than in half of the cases | Almost always | ||||
|---|---|---|---|---|---|---|---|---|---|---|
0 | 1 | 2 | 3 | 4 | 5 | |||||
1. How often in the past month have you had the sensation of not emptying your bladder completely after you finished urinating? | ||||||||||
2. How often in the past month have you had to urinate less than 2 hours after you finished urinating? | ||||||||||
3. Over the past month, how often have you found you stopped and started again several times when you urinated? | ||||||||||
4. Over the past month, how often have you found it difficult to postpone urination? | ||||||||||
5. How often in the past month have you had a weak urinary stream? | ||||||||||
6. How often in the past month have you had to push or strain to begin urination? | ||||||||||
No | 1 time | 2 times | 3 times | 4 times | 5 or more times | |||||
7. How often in the past month have you had to get up from bed to urinate during the night? | ||||||||||
Total I-PSS score = | ||||||||||
Quality of life due to urinary symptoms | ||||||||||
If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? Quality of life index L= | Delighted | Good | Satisfactory | Mostly satisfied | Unsatisfactory | Mostly dissatisfied | Unhappy | |||
0 | 1 | 2 | 3 | 4 | 5 | 6 | ||||
Key (interpretation): Total score:
0 to 7 indicates mild symptoms,
8 to 19 indicates moderate symptoms,
20 to 35 indicates severe disease symptoms
Notes: The International Prostate Symptom Score (IPSS) questionnaire allows for the assessment of symptom severity in patients with voiding dysfunction. Based on the score, the physician determines the severity of the patient's symptoms and selects an appropriate treatment approach. The quality of life index is used as an additional assessment method. The results of the IPSS questionnaire can only be fully interpreted during a medical consultation, where the physician, prior to making any assessments, will thoroughly review the patient's complaints and medical history, perform a physical examination, and conduct additional tests and investigations aimed at identifying the causes of urinary disorders. Therefore, you should not attempt to obtain a virtual interpretation of the IPSS questionnaire or any recommendations regarding examination or treatment. It is intended solely for your convenience so that you can print it out, complete it, and bring it to your doctor's appointment.
Appendix G2. Questionnaire for assessing the outcomes of surgical treatment in patients with anterior urethral strictures.
Russian title: questionnaire for assessing the outcomes of surgical treatment in patients with anterior urethral strictures
Original title (if applicable): Patient-Reported Outcome Measure for Urethral Stricture Surgery
Source (official developer website, validation publication):
Bazaev, V. V. Validation of the Russian-language version of the patient-reported outcome measure for urethral stricture surgery (PROM-USS) questionnaire: results of a pilot study / V. V. Bazaev, A. N. Shibaev, Yu. V. Pavlova // Urologiya. – 2015. – No. 5. – P. 15–21.
Jackson M.J., Sciberras J., Mangera A., Brett A., Watkin N., N"dow J.M., Chapple C.R., Andrich D.E., Pickard R.S., Mundy A.R. Defining a patient-reported outcome measure for urethral stricture surgery. Eur Urol. 2011;60: 60–68. _____________________________________________________________________
Type (underline):
- rating scale
- index
- questionnaire
Purpose: _ assessment of surgical treatment outcomes in patients with anterior urethral strictures
Content (template):
Thank you for agreeing to complete this questionnaire. The questions
are designed to assess the impact of urethral strictures on patients'
quality of life. Some questions may seem repetitive; however, they are distinct.
Please take the time to read each question carefully. Select the answer
that MOST accurately describes your symptoms over the past 4 weeks. If you
have an indwelling urethral catheter or a suprapubic catheter (a catheter in the lower abdomen), please begin answering from question 11.
1. Do you experience difficulty initiating urination?
Never
Occasionally
Sometimes
Most of the time
Always
2. How would you describe your urinary stream?
Normal
Occasionally decreased
Sometimes decreased
Decreased most of the time
Always decreased
3. Do you have to strain to continue urinating?
Never
Periodically
Sometimes
Most of the time
Always
4. Do you experience urinary stream interruption more than once during a single urination?
Never
Periodically
Sometimes
Most of the time
Always
5. How often do you experience a feeling of incomplete bladder
emptying after urination?
Never
Periodically
Sometimes
Most of the time
Always
6. How often, after you have finished urinating and dressed, do you
experience involuntary urine leakage/wetting of underwear?
Never
Periodically
Sometimes
Most of the time
Always
7. Rate how much the symptoms associated with urination
affect your life:
Not at all
Slightly
Somewhat
Significantly
8. Select the number that corresponds to your urinary stream force over the past month:
9. Are you satisfied with the outcome of the surgery?
Yes, very satisfied
Yes, satisfied
No, not satisfied
No, completely dissatisfied
10. If you are not satisfied, it is because…
Quality of urination has not improved
Quality of urination has improved, but new problems
have appeared
The quality of urination has not improved and new
problems
Please tick one box in each of the sections below.
Select the answers that best describe your health state today.
11. Mobility:
I have no problems in walking
I have some problems in walking
I am confined to bed
151
12. Self-care:
I have no problems with self-care
I have some problems washing or
dressing myself
I am unable to wash or dress myself
13. Usual activities (e.g., work, study, housework, family or leisure activities):
My usual activities
comes easily to me
My everyday activities are
somewhat difficult for me
I am unable to perform my everyday
activities
14. Pain/discomfort:
I have no pain or discomfort
I have moderate pain or discomfort
I have severe pain or discomfort
15. Anxiety/depression:
I am not anxious or depressed
I am moderately anxious or depressed
I am severely anxious or depressed
To help people express how good or bad their health state is, we have drawn a scale resembling a thermometer on which the best health you can imagine is marked by 100 and the worst by 0.
We would like you to indicate on this scale how good or bad your health state is today, in your opinion. To do this, draw a line from bottom to top
to the point on the scale that corresponds to your current health status.
Key (interpretation):
lower urinary tract symptoms (LUTS) block, consisting of 6 questions (Q 1–6) based on the ICIQ-MLUTS questionnaire, where 0 points = no symptoms, 24 points = maximum symptom severity;
a separate question to assess the impact of LUTS on QoL (Q-7) – evaluated using the Likert scale: not at all; a little, moderately, severely;
visual analogue scale (VAS) for assessing urinary stream (Q 8) – allows assessing the urinary stream from 1 (best) to 4 (worst).
EQ-5D-3L questionnaire for general QoL assessment. The VAS "thermometer" (EQ-VAS) prompts marking the "overall health status" on a vertical scale from 100 for "best imaginable health state" to 0 for "worst imaginable health state". The descriptive part of EQ-5D is expressed as a health profile including mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Profiles can be converted into a single summary index score, the EQ-5D index.
The questionnaire has two versions (pre- and postoperative). The postoperative version includes two additional questions about patient satisfaction with treatment outcomes (Q-9 and Q-10).
Notes: The questionnaire evaluates the man's condition over the past 4 weeks and is completed independently by the patient. Men with no spontaneous urination who have a cystostomy drainage or urethral catheter may skip the questions in the first part of the questionnaire, as additionally specified in the form.
Appendix G3. International Index of Erectile Function (IIEF-5).
Russian title: International Index of Erectile Function (IIEF-5).
Original title (if applicable): _________________________________
Source (official developer website, validation publication):
R C Rosen, J C Cappelleri, M D Smith, J Lipsky, B M Peña International Journal of Impotence Research 1999, 11 (6): 319–26.
_________________________________________________________________________
Type (underline):
- rating scale
- index
- questionnaire
Purpose: ________________________________________________________
Content (template):
International Index of Erectile Function (IIEF-5)
Full Name: _________________________________________________________ Date: _____________________________
1 | How often were you able to get an erection during sexual activity? | 1 Almost never or never | 2 A few times (much less than half the time) | 3 Sometimes (about half the time) | 4 Most times (much more than half the time) | 5 Almost always or always |
|---|---|---|---|---|---|---|
2 | When you had erections with sexual stimulation, how often were your erections hard enough for penetration? | 1 Almost never or never | 2 A few times (much less than half the time) | 3 Sometimes (about half the time) | 4 Most times (much more than half the time) | 5 Almost always or always |
3 | When you attempted sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? | 1 Almost never or never | 2 A few times (much less than half the time) | 3 Sometimes (about half the time) | 4 Most times (much more than half the time) | 5 Almost always or always |
4 | During sexual intercourse, how difficult was it to maintain your erection to the completion of intercourse? | 1 Extremely difficult | 2 Very difficult | 3 Difficult | 4 Slightly difficult | 5 Not difficult |
5 | How often did you derive pleasure from sexual intercourse? | 1 Almost never or never | 2 A few times (much less than half the time) | 3 Sometimes (about half the time) | 4 Most times (much more than half the time) | 5 Almost always or always |
Key (interpretation):
Score interpretation:
21–25 points: no erectile dysfunction
16–20 points: mild erectile dysfunction
11–15 points: mild-to-moderate erectile dysfunction
5–10 points: moderate-to-severe erectile dysfunction
Notes: The IIEF-5 (International Index of Erectile Function) scale evaluates a man's sexual function regarding his ability to achieve and maintain an erection sufficient for satisfactory sexual intercourse. This scale is one of the diagnostic tools used to determine whether a man suffers from erectile dysfunction and, if so, to what degree.