An additional test that we find to be very useful to evaluate a stricture is the cystoscopy. This cystoscopy is done in the office and is typically done one the same day as the retrograde urethrogram. After local anesthesia (usually lidocaine jelly) has been placed into the urethra a cystoscope is gently placed into the urethra. The cystoscopy allow direct visualization of the urethra as well as any other anatomic anomalies that may be present in the urethra. In addition, the cystoscopy may also reveal urethral lesions that are not well visualized on a retrograde urethrogram. The downside of the cystoscopy is that often a cystoscope will be too wide to permit passage through the narrow opening of the urethral stricture and, consequently, it can be difficult to estimate the length of the urethral stricture as well as the presence of additional strictures behind the impassable one. For this reason, we feel that a cystoscopy generally should be done in conjunction with the retrograde urethrogram to diagnose and evaluate urethral strictures.
The cystoscopy is useful to evaluate urethral strictures in other ways also. Dr. Purohit and Blaivas have developed and published a staging system for urethral strictures that relies on the use of cystoscopy. It is currently the only validated staging system available for describing urethral strictures. Typically, urethral strictures have been studied using a binary scale (or 2 part) in the medical literature – that is patients are reported as either having a stricture or not. We have found that the simple binary classification of strictures and analysis that are based on the simple binary staging system of strictures is often inadequate to fully describe the range of urethral strictures that patients can develop. Some strictures are very slight narrowing in the urethra that causes no symptoms and may never become a problem for patients. Other urethral strictures, however, are very tight and cause terrible suffering for patients. Our staging system is the first step to better incorporate the large variety of strictures. In our opinion not all strictures should be treated the same – in fact some strictures may not need any surgery at all!
Dr. Purohit and Dr. Blaivas’ approach incorporates the staging system and allows a more nuanced and individualized surgery. The Purohit-Blaivas urethral stricture staging system uses a 4-point system to describe the range of strictures that patients can have; it is based on cystoscopic findings alone. By having a four tiered system, we are able to better describe and study the range of strictures that the patients present with.
The staging system is as shown below.