Perineal urethrostomy

Overview

Perineal urethrostomy is a surgical procedure designed to restore normal urination by bypassing a blockage caused by a urethral stricture. This surgery involves creating a new opening in the urethra through the perineum, the area between the scrotum and anus.

The urethra is the tube that transports urine from the bladder out through the penis. During urination, urine flows through this tube and exits at the tip of the penis. Urethral stricture, which is the narrowing of the urethra, can occur due to factors such as infection, injury, or prior surgery. When the urethra becomes too narrow, it can obstruct urine flow, making urination difficult.

Perineal urethrostomy is performed to alleviate this obstruction. The procedure is considered safe, rarely results in complications, and does not lead to incontinence.

Reasons for undergoing the procedure

A perineal urethrostomy is generally advised only when previous surgeries to fix a urethral stricture have failed and the urethra cannot be repaired for normal urination. After the procedure, men will urinate while seated, as the urine exits through a new opening in the perineum instead of through the end of the penis.

This procedure could be an option for older men with anterior urethral strictures who want to avoid more extensive reconstructive urethral surgery.

Perineal urethrostomy may be recommended for the following cases:

• Failure of earlier reconstructive surgeries, like urethroplasty.
• Surgical resection after Fournier’s gangrene affecting the penis and scrotum.
• Penectomy: The surgical procedure to remove the penis.
• Urethrectomy: The surgical procedure to remove either part or all of the urethra.
• Hypospadias: A congenital defect where the opening of the penis is on the underside.
• Complex or recurrent urethral strictures
• Squamous cell carcinoma of the penis

Risks

Potential complications of perineal urethrostomy include:

• Urinary tract infection
• Low urinary flow
• Increased residual urine in the bladder

While these complications are rare, it is important to monitor one’s condition. 

Other possible issues are bleeding, swelling, infection, fever, and recurrence of the urethral stricture, which might need more surgery. There is also a risk of cardiovascular problems.

Before the procedure

Prior the surgery, one should inform their healthcare provider if they have:

• A prescription for a blood-thinning drug such as dabigatran, rivaroxaban, aspirin, clopidogrel, or warfarin.
• MRSA infection. 
• High-risk of variant CJD.
• Implants such as stents, joint replacements, pacemakers, heart valves, or blood vessel grafts.

These may also be required prior to a perineal urethrostomy:

• Provide a urine sample for analysis
• Undergo X-rays of the urethra to assess its condition
• Receive broad-spectrum antibiotics to prevent urinary tract infections

During the procedure

Perineal urethrostomy can be done in various ways, with the Blandy technique being the most common method.

The healthcare provider usually proceeds as follows:

• Administer general anesthesia
• Make an inverted U-shaped incision in the perineum, located just below the scrotum
• Open the skin to expose the bulbar urethra
• Make a lengthwise incision approximately 3 to 4 centimeters long in the urethra
• Suture the upper part of the perineal skin flap to the nearest segment of the opened urethra
• Stitch the edges of the perineal flap to the edges of the urethral mucosa
• Stitch the scrotal skin to the upper part of the urethral opening until it aligns with the perineal flap, thereby completing the formation of the opening.
• A Foley catheter is inserted into the bladder through the urethrostomy to facilitate urine drainage

After the procedure

After the surgery, follow-up visits is scheduled to monitor recovery, which may include a catheter removal appointment.

Before leaving the hospital, the healthcare provider will also instruct the patient on home care and provide necessary antibiotics or pain medications.

Outcome

Following the surgery, a catheter is typically in place for two to three weeks, during which time you will receive antibiotics and pain relief. In some cases, the catheter may need to remain in place for a longer period.

Follow-up visits are scheduled to monitor your progress, and a cystourethroscopy is usually performed 8 to 12 months after the surgery to evaluate the urethra for any potential issues. The urinary flow rate and residual urine volume might be assessed every six months to a year.

To ensure a smooth recovery after perineal urethrostomy, it’s crucial to contact your healthcare provider if you experience any complications, such as heavy bleeding, swelling, infection, fever, urinary tract infection, residual urine in the bladder after urination, reduced urine flow, recurrence of the stricture, or cardiovascular issues.