16565 Perineal Urethrostomy

Overview

A perineal urethrostomy is an operation that makes a new opening for urine to leave your body. Urine normally travels from your bladder, through a tube called the urethra, and out through the tip of the penis. If part of that tube becomes narrow or blocked — doctors call this a stricture — urine cannot flow well. In this operation, the surgeon brings a healthy, wider part of the urethra to a small opening in the perineum. The perineum is the patch of skin between the scrotum and the anus. After the operation, you pass urine from this new opening rather than from the tip of the penis, and you will normally sit down to urinate. The change is permanent.

Narrowing of the urethra is not common, and a perineal urethrostomy is done far less often than other stricture treatments. It is a well-established operation that urology surgeons (specialists in the urinary system) perform regularly, so most urology teams have a lot of experience with it.

It is done almost always in men, or people who were born with a penis. It is more likely to be suggested if you have a long stricture, a stricture caused by a skin condition called lichen sclerosus (a long-term skin inflammation that can scar and tighten skin), scarring after injury or long-term catheter use, or if earlier repair operations did not succeed. Some older men with other health problems choose it because it is a shorter, simpler operation than a full rebuild of the urethra.

Symptoms

Common symptoms

• A weak or thin urine stream, or a stream that sprays or splits
• Having to strain or push to start urinating
• Dribbling at the end, or feeling your bladder is not fully empty
• Needing to urinate often, or getting up at night to go
• Burning or stinging when you pass urine
• Urine infections that keep coming back
• Sometimes blood in the urine or pain in the penis or perineum

Symptoms in children

• Strictures in children are uncommon and are often linked to earlier surgery or injury
• Signs can include a very thin stream, spraying, straining, or wetting after using the toilet
• A child may not be able to describe the problem, so trouble toilet training or repeated urine infections are important clues
• Any child who cannot pass urine needs urgent medical help straight away

Symptoms in older adults

• Symptoms may be put down to prostate enlargement, so a stricture can be missed at first
• Lichen sclerosus becomes more common with age and can cause both stricture and skin tightening
• A history of long-term catheters or repeated bladder tests raises the chance of scarring
• Other health conditions may make a shorter operation like this one a safer choice than a long rebuild

Causes

Main causes

• Scarring from a skin condition called lichen sclerosus, which tightens and narrows the urethra
• Injury to the perineum, such as falling astride something hard like a bike frame
• Long-term or repeated use of a urinary catheter, or repeated tube tests in the bladder
• Scarring after prostate surgery, other urinary surgery, or radiotherapy to the pelvis
• Some urine infections, and in children, surgery for conditions present at birth
• Often no clear cause is found

Risk factors

• A long stricture, or more than one narrowed area
• Lichen sclerosus or other long-term skin conditions around the genitals
• Previous stricture operations that did not last
• Diabetes, which can make scarring and infection more likely
• Smoking, which slows healing
• Being older and having other health conditions that make longer operations riskier

When to see a doctor

See a doctor urgently if:

• You cannot pass urine at all — get emergency help right away
• Fever with back or side pain, or feeling very unwell
• Visible blood in your urine
• A urine infection that keeps returning despite treatment

Book a routine appointment if:

• Your urine stream has become weaker or slower over weeks or months
• You need to strain to urinate, or your bladder never feels empty
• You are getting up several times a night to urinate
• Your doctor has mentioned a urethral stricture and you want to talk through options, including surgery
• You have a new opening after surgery and notice it is getting narrower, or the skin around it is red and sore

Diagnosis

Your doctor will ask about your urine flow, infections, injuries, catheters and past surgery, and will examine you, including the penis and perineum. They may ask you to urinate into a special toilet that measures how fast your stream flows. If a stricture is suspected, you will usually be referred to a urology team, who use imaging and a small camera to see exactly where and how long the narrowing is. That information decides whether a perineal urethrostomy is the right option for you.

Tests that may be done

• Uroflowmetry: you urinate into a machine that measures your flow rate
• Bladder scan: a painless ultrasound scan to see how much urine is left in your bladder after you go
• Retrograde urethrogram: an X-ray taken after a dye is gently passed into the urethra so the narrowing shows up
• Cystoscopy: a thin flexible tube with a tiny camera looks inside the urethra, usually with some numbing gel
• Urine test to check for infection
• Blood tests, and sometimes a biopsy of the skin, if lichen sclerosus is suspected

What to expect at your appointment

Most of these tests are quick and can be done in a clinic. The camera test can feel a little uncomfortable, like a strong need to urinate, and it passes quickly. You will normally be told not to urinate just before the flow test. Your urology team will explain the results and talk through all the treatment choices with you before any decision is made.

Treatment

Treatment aims to get urine flowing freely again and to protect your kidneys. Some narrowings can be treated with stretching or a small internal cut, but these often close up again, especially with long strictures. Rebuilding the urethra (called urethroplasty) can work well for some men but is a bigger operation. A perineal urethrostomy is chosen when those options are unlikely to last or are not safe for you. It is a shorter operation with good, lasting results.

Self-care at home

• Drink enough fluid so your urine stays pale — this helps keep the new opening clean
• Sit down to urinate, and take your time so your bladder empties fully
• Keep the area clean with plain warm water and mild soap, and pat dry gently
• Follow your surgeon's advice on wound care, bathing and when to return to work or exercise
• Avoid heavy lifting, cycling and straining for as long as your team advises after surgery
• Take any prescribed pain relief as directed, and ask your pharmacist if you are unsure
• Go to all follow-up appointments so the new opening can be checked

Medical treatments

No medicine can widen a scarred urethra. Some people are first offered a procedure to stretch the narrowing or a small internal cut, done through the urethra, but these often close up again over months. Antibiotics may be used if you have a urine infection, and creams may be used if you have lichen sclerosus, but these treat infection and skin inflammation rather than the scar itself. If narrowing keeps coming back, your urology team will discuss surgical options with you. Your doctor or pharmacist can explain any medicine prescribed to you.

When is surgery considered?

Surgery is considered when the narrowing keeps coming back, when it is long or in a difficult place, when you cannot empty your bladder properly, or when infections or kidney problems keep happening. A perineal urethrostomy may be recommended as a first option if rebuilding the urethra is unlikely to work or would be too big an operation for you, and as a next step if earlier repairs have failed. It is done under a general or spinal anaesthetic, usually takes around one to two hours, and often means a short stay in hospital. A thin tube may be left in for a few days to keep the new opening clear while it heals.

Living with this condition

After healing, most people urinate comfortably by sitting down. The new opening is in the perineum, so you will not urinate through the tip of the penis any more. Some men find the first few weeks awkward while they get used to it, and it helps to keep a small supply of wipes or pads handy at first. The new opening can occasionally tighten over time, so keeping follow-up appointments matters. Many people say the relief from years of difficult urination makes the change well worth it.

Lifestyle tips

• Wear loose, comfortable underwear and clothing while healing
• Keep up gentle walking once your team says it is fine, to help healing and circulation
• Stay well hydrated, especially in hot weather or when exercising
• Wash your hands before and after touching the area, and keep the opening clean and dry
• Tell any doctor, nurse or dentist that you have a perineal urethrostomy, because it changes how urine samples and catheters are handled
• Carry a small card or note about your operation in case you need care elsewhere

Diet and exercise

There is no special diet, but eating fibre-rich foods and drinking enough fluid helps prevent constipation, which makes straining less likely. Spicy foods, caffeine and alcohol bother some people's bladders — notice what affects you. Avoid cycling, horse riding and heavy weights until your surgeon clears you, then build up slowly. Regular movement helps healing, sleep and mood.

Mental health and emotional wellbeing

It is completely normal to feel worried, embarrassed or low before or after this operation. Changes to how you urinate and how your body looks and works can affect confidence, relationships and body image. These feelings usually ease as you recover and get used to the new routine, but they deserve to be taken seriously. If you feel persistently low, anxious, or unable to cope, please tell your GP or urology team — effective support is available. If you ever have thoughts of harming yourself, contact your local crisis line or emergency services straight away.

Prevention

Not all strictures can be prevented, because many come from skin conditions or injuries that are outside your control. Even so, some practical steps lower the risk: avoid unnecessary catheters, get catheters changed on schedule and removed as soon as possible, treat genital skin inflammation early, use proper protection when cycling or riding, and see your doctor promptly if your urine flow changes or infections keep returning. If you already have a stricture, early treatment can stop it getting longer and harder to manage.

Vaccines

There is no vaccine for urethral stricture. Staying up to date with routine vaccinations is still good general health advice, and your GP or pharmacist can advise you.

Screening programmes

There is no routine screening programme for urethral stricture. If you have lichen sclerosus, a history of catheter use, or previous urinary surgery, ask your doctor to check your urine flow at your regular reviews.

Complications

If left untreated

• Urine may build up and you may suddenly be unable to pass any at all, which is an emergency
• Repeated urine infections, and sometimes bladder stones
• Back-pressure on the kidneys over time, which can damage them
• Increasing discomfort, poor sleep and a big impact on daily life
• After surgery, possible problems include bleeding, infection, narrowing of the new opening, a small leak of urine through nearby skin, or spraying — most of these can be treated, and sometimes a small revision is needed

Long-term outlook

The outlook is generally good. A perineal urethrostomy is one of the most reliable ways to restore free urine flow when the urethra is badly narrowed, and most people get lasting relief and a much better quality of life. Healing takes a few weeks, and you will have follow-up to make sure the new opening stays wide. Some people need a small procedure later if it tightens, which is usually straightforward. With regular checks and good hydration, most people settle into a normal routine.

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